Provider Demographics
NPI:1104880301
Name:GLAZENER, WESLEY STANTON (MD)
Entity type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:STANTON
Last Name:GLAZENER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1305 W 34TH ST
Mailing Address - Street 2:#206
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1923
Mailing Address - Country:US
Mailing Address - Phone:512-454-8691
Mailing Address - Fax:512-454-4238
Practice Address - Street 1:1305 W 34TH ST
Practice Address - Street 2:#206
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1923
Practice Address - Country:US
Practice Address - Phone:512-454-8691
Practice Address - Fax:512-454-4238
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7305208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F41261Medicare UPIN