Basic Information
| Provider Information | |||||||||
| NPI: | 1720023070 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PICKENS | ||||||||
| FirstName: | GLYNN | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PICKENS | ||||||||
| OtherFirstName: | JOHN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3600 GASTON AVE | ||||||||
| Address2: | SUITE 1205 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752461800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146928262 | ||||||||
| FaxNumber: | 2146964190 | ||||||||
| Practice Location | |||||||||
| Address1: | 890 ROCKWALL PKWY | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | ROCKWALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750326872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722766191 | ||||||||
| FaxNumber: | 9724546893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 01/31/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | J0199 | TX | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 045376302 | 05 | TX | MEDICAID |