Basic Information
Provider Information
NPI: 1003806431
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DAVIS
FirstName: GLENN
MiddleName: R
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2255 E MOSSY OAKS RD STE 680
Address2:  
City: SPRING
State: TX
PostalCode: 773891812
CountryCode: US
TelephoneNumber: 2815370300
FaxNumber: 2815370315
Practice Location
Address1: 2255 E MOSSY OAKS RD STE 680
Address2:  
City: SPRING
State: TX
PostalCode: 773891812
CountryCode: US
TelephoneNumber: 2815370300
FaxNumber: 2815370315
Other Information
ProviderEnumerationDate: 10/26/2005
LastUpdateDate: 12/11/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 12/11/2019

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000XK5503TXY Allopathic & Osteopathic PhysiciansInternal Medicine 
208000000XK5503TXN Allopathic & Osteopathic PhysiciansPediatrics 

ID Information
IDTypeStateIssuerDescription
11024033401TXMEDICARE RAILROAD PINOTHER


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