Basic Information
| Provider Information | |||||||||
| NPI: | 1962442350 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IHDE | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3555 KNICKERBOCKER RD | ||||||||
| Address2: | |||||||||
| City: | SAN ANGELO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 769047610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3259499555 | ||||||||
| FaxNumber: | 3252245024 | ||||||||
| Practice Location | |||||||||
| Address1: | 3555 KNICKERBOCKER RD | ||||||||
| Address2: | |||||||||
| City: | SAN ANGELO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 769047610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3259499555 | ||||||||
| FaxNumber: | 3252245024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 10/07/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | K6010 | TX | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.