Basic Information
| Provider Information | |||||||||
| NPI: | 1033135876 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERS-DO | ||||||||
| FirstName: | GLENDA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9900 S IH 35 | ||||||||
| Address2: | TEXAS MEDCLINIC | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787483885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122915577 | ||||||||
| FaxNumber: | 5122915576 | ||||||||
| Practice Location | |||||||||
| Address1: | 9900 S IH 35 | ||||||||
| Address2: | TEXAS MEDCLINIC | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787483885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122915577 | ||||||||
| FaxNumber: | 5122915576 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 11/10/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | J8713 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | J8713 | 01 | TX | TEXAS MEDICAL LICENSE | OTHER | 1119812-01 | 05 | TX | MEDICAID | 72-1564406 | 01 | TX | FEDERAL TAX ID | OTHER |