Provider Demographics
NPI:1104921873
Name:MCGLOTHLIN, JEFFERY C (MD)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:C
Last Name:MCGLOTHLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99371
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0371
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-7347
Practice Address - Street 1:1500 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:682-885-2500
Practice Address - Fax:682-885-2510
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH54692084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123977OtherSUPERIOR PIN
TX4397262OtherAETNA PIN
TX10010109OtherAMERIGROUP PIN
TX87V784OtherBCBSTX IND PIN
TX9360939OtherCIGNA PIN
TX1750369203OtherGPR NPI NUMBER
TX00U87ZOtherBCBSTX GRP PIN
TX119063100OtherFIRSTCARE PIN
TX023247201Medicaid
TX120608801Medicaid
TX120608802Medicaid
TX140442803Medicaid
TX1436086OtherUHC PIN
TX1640340OtherFIRSTHEALTH PIN
TX120608802Medicaid
TX140442803Medicaid
TX00L98SMedicare PIN