Basic Information
| Provider Information | |||||||||
| NPI: | 1104921873 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGLOTHLIN | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99371 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851855 | ||||||||
| FaxNumber: | 6828857347 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 COOPER ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828852500 | ||||||||
| FaxNumber: | 6828852510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 04/02/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | H5469 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
| ID | Type | State | Issuer | Description | 123977 | 01 | TX | SUPERIOR PIN | OTHER | 4397262 | 01 | TX | AETNA PIN | OTHER | 10010109 | 01 | TX | AMERIGROUP PIN | OTHER | 87V784 | 01 | TX | BCBSTX IND PIN | OTHER | 9360939 | 01 | TX | CIGNA PIN | OTHER | 1750369203 | 01 | TX | GPR NPI NUMBER | OTHER | 00U87Z | 01 | TX | BCBSTX GRP PIN | OTHER | 119063100 | 01 | TX | FIRSTCARE PIN | OTHER | 023247201 | 05 | TX | MEDICAID | 120608801 | 05 | TX | MEDICAID | 120608802 | 05 | TX | MEDICAID | 140442803 | 05 | TX | MEDICAID | 1436086 | 01 | TX | UHC PIN | OTHER | 1640340 | 01 | TX | FIRSTHEALTH PIN | OTHER |