Healthcare Provider Details

I. General information

NPI: 1265425656
Provider Name (Legal Business Name): GLENN D MCCLENDON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 DAVE WARD DR STE 1
CONWAY AR
72034-8686
US

IV. Provider business mailing address

2425 DAVE WARD DR STE 1
CONWAY AR
72034-8686
US

V. Phone/Fax

Practice location:
  • Phone: 501-504-2737
  • Fax: 501-499-9890
Mailing address:
  • Phone: 501-504-2737
  • Fax: 501-499-9890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number140
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: