Healthcare Provider Details

I. General information

NPI: 1649763541
Provider Name (Legal Business Name): ROLAND T GLENISTER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 11TH STREET UNIT B
WICHITA FALLS TX
76301-4332
US

IV. Provider business mailing address

1631 11TH STREET UNIT B
WICHITA FALLS TX
76301-4332
US

V. Phone/Fax

Practice location:
  • Phone: 940-263-3000
  • Fax: 940-263-3018
Mailing address:
  • Phone: 940-263-3000
  • Fax: 940-263-3018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberS3905
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberS3905
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: