Provider Demographics
NPI:1053414938
Name:PABODY, GLENN D (PA)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:D
Last Name:PABODY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:12377 MERIT DR STE 300
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251-3126
Mailing Address - Country:US
Mailing Address - Phone:972-957-3000
Mailing Address - Fax:972-957-3005
Practice Address - Street 1:2815 S HAMPTON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75224-2329
Practice Address - Country:US
Practice Address - Phone:214-330-0137
Practice Address - Fax:214-333-7343
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA02385363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS95885Medicare UPIN
TX83N527Medicare PIN