MEDICARE: DR. BRIAN GLODT M.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	208D00000X	General Practice Physician	U1018	TX
2	208000000X	Pediatrics Physician	U1018	TX

General Provider Information

NPI Number	:	1467575266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN GLODT M.D.

Provider Business Mailing Address
First Line	:	111 STATE PARK DR
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23664-1965
Country	:	US
Telephone Number	:	301-257-0665
Fax Number	:

Provider Business Practice Location Address
First Line	:	2312 WESTERN TRAILS BLVD STE 103
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78745-1642
Country	:	US
Telephone Number	:	512-840-1273
Fax Number	:

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

Provider Enumeration Date	:	04/08/2007
Last Update Date	:	09/29/2023

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