Provider Demographics
NPI:1699442087
Name:GEORGE, GLADVIN
Entity type:Individual
Prefix:
First Name:GLADVIN
Middle Name:
Last Name:GEORGE
Suffix:
Gender:M
Credentials:
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 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:405-210-0274
Mailing Address - Fax:
Practice Address - Street 1:6201 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7201
Practice Address - Country:US
Practice Address - Phone:214-648-8998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA18110363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant