MEDICARE: GLENN GORDON DESHAW O.D.

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	152W00000X	Optometrist	2204TG	TX

General Provider Information

NPI Number	:	1346284643
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN GORDON DESHAW O.D.

Provider Business Mailing Address
First Line	:	2636 W WALNUT ST
Second Line	:	STE 200
City	:	GARLAND
State	:	TX
Zip	:	75042-6441
Country	:	US
Telephone Number	:	972-485-0700
Fax Number	:	972-485-0702

Provider Business Practice Location Address
First Line	:	2636 W WALNUT ST
Second Line	:	STE 200
City	:	GARLAND
State	:	TX
Zip	:	75042-6441
Country	:	US
Telephone Number	:	972-485-0700
Fax Number	:	972-485-0702

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

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	07/21/2011

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