Healthcare Provider Details

I. General information

NPI: 1982923975
Provider Name (Legal Business Name): SHANNON B. GLASS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2010
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11937 US HIGHWAY 271
TYLER TX
75708
US

IV. Provider business mailing address

PO BOX 846098
DALLAS TX
75284-1656
US

V. Phone/Fax

Practice location:
  • Phone: 903-877-7777
  • Fax:
Mailing address:
  • Phone: 903-531-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberQ1611
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: