Provider Demographics
NPI:1063512432
Name:WILLIAMS JR, GLEN (RTRCTCVMR)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:WILLIAMS JR
Suffix:
Gender:M
Credentials:RTRCTCVMR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16107 BEECHNUT ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77083
Mailing Address - Country:US
Mailing Address - Phone:713-791-1414
Mailing Address - Fax:
Practice Address - Street 1:16107 BEECHNUT ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083
Practice Address - Country:US
Practice Address - Phone:713-791-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2121902471C1106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C1106XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistCardiac-Interventional Technology