Healthcare Provider Details

I. General information

NPI: 1487839981
Provider Name (Legal Business Name): DANIEL ADAM GLASS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2008
Last Update Date: 12/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1136 E GRANDE BLVD
TYLER TX
75703-3982
US

IV. Provider business mailing address

1136 E GRANDE BLVD
TYLER TX
75703-3982
US

V. Phone/Fax

Practice location:
  • Phone: 903-592-5601
  • Fax: 903-595-3304
Mailing address:
  • Phone: 903-592-5601
  • Fax: 903-595-3304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberP3333
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: