Provider Demographics
NPI:1528155082
Name:AUSTIN, GLEN D (DO)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:D
Last Name:AUSTIN
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Gender:M
Credentials:DO
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Mailing Address - Street 1:1501 S YALE ST
Mailing Address - Street 2:STE# 252
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-7304
Mailing Address - Country:US
Mailing Address - Phone:928-774-1811
Mailing Address - Fax:928-774-2001
Practice Address - Street 1:1501 S YALE ST
Practice Address - Street 2:STE# 252
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-7304
Practice Address - Country:US
Practice Address - Phone:928-774-1811
Practice Address - Fax:928-774-2001
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2013-07-22
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Provider Licenses
StateLicense IDTaxonomies
AZ4261208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ973108Medicaid