Healthcare Provider Details

I. General information

NPI: 1053414938
Provider Name (Legal Business Name): GLENN D PABODY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 S HAMPTON RD
DALLAS TX
75224-2329
US

IV. Provider business mailing address

12377 MERIT DR STE 300
DALLAS TX
75251-3126
US

V. Phone/Fax

Practice location:
  • Phone: 214-330-0137
  • Fax: 214-333-7343
Mailing address:
  • Phone: 972-957-3000
  • Fax: 972-957-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA02385
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA02385
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: