Provider Demographics
NPI:1154725372
Name:GLENN J WILCOX
Entity type:Organization
Organization Name:GLENN J WILCOX
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:214-526-3336
Mailing Address - Street 1:3300 DOUGLAS AVE
Mailing Address - Street 2:STE B
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-2723
Mailing Address - Country:US
Mailing Address - Phone:214-526-3336
Mailing Address - Fax:214-526-3337
Practice Address - Street 1:3300 DOUGLAS AVE
Practice Address - Street 2:STE B
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-2723
Practice Address - Country:US
Practice Address - Phone:214-526-3336
Practice Address - Fax:214-526-3337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1394213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty