MEDICARE: BRIAN DALE GLASER D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	L6912	TX

General Provider Information

NPI Number	:	1083672067
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN DALE GLASER D.O.

Provider Business Mailing Address
First Line	:	3400 LONG PRAIRIE ROAD
Second Line	:	SUITE 200
City	:	FLOWER MOUND
State	:	TX
Zip	:	75022-2706
Country	:	US
Telephone Number	:	972-899-6300
Fax Number	:	972-899-6020

Provider Business Practice Location Address
First Line	:	3400 LONG PRAIRIE ROAD
Second Line	:	SUITE 200
City	:	FLOWER MOUND
State	:	TX
Zip	:	75022-2706
Country	:	US
Telephone Number	:	972-899-6300
Fax Number	:	972-899-6020

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	02/16/2015

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