Basic Information
| Provider Information | |||||||||
| NPI: | 1780038729 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLOVER | ||||||||
| FirstName: | LAKEBRA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11511 SHADOW CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | PEARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775847298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134420000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25553 US HIGHWAY 59 | ||||||||
| Address2: | |||||||||
| City: | PORTER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773655500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134422100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2016 | ||||||||
| LastUpdateDate: | 04/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | S2584 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 402965403 | 05 | TX | MEDICAID | 402965402 | 05 | TX | MEDICAID | 402965401 | 05 | TX | MEDICAID |