Provider Demographics
NPI:1588898589
Name:GLENN WOOD MD PA
Entity type:Organization
Organization Name:GLENN WOOD MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-892-7200
Mailing Address - Street 1:5339 N IH 35
Mailing Address - Street 2:100
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-2428
Mailing Address - Country:US
Mailing Address - Phone:512-892-7200
Mailing Address - Fax:512-892-7205
Practice Address - Street 1:5339 N IH 35
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-2428
Practice Address - Country:US
Practice Address - Phone:512-892-7200
Practice Address - Fax:512-892-7205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-06
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153715101Medicaid
TX082009401Medicaid
TX153715103Medicaid
TX153715105Medicaid