Healthcare Provider Details

I. General information

NPI: 1467575266
Provider Name (Legal Business Name): BRIAN GLODT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2007
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2312 WESTERN TRAILS BLVD STE 103
AUSTIN TX
78745-1642
US

IV. Provider business mailing address

111 STATE PARK DR
HAMPTON VA
23664-1965
US

V. Phone/Fax

Practice location:
  • Phone: 512-840-1273
  • Fax:
Mailing address:
  • Phone: 301-257-0665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberU1018
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberU1018
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: