Provider Demographics
NPI:1134218779
Name:WHEELESS, GLENN STEPHEN (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:STEPHEN
Last Name:WHEELESS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4780 N JOSEY LN
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4615
Mailing Address - Country:US
Mailing Address - Phone:972-492-1334
Mailing Address - Fax:972-492-5174
Practice Address - Street 1:4780 N JOSEY LN
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4615
Practice Address - Country:US
Practice Address - Phone:972-492-1334
Practice Address - Fax:972-492-5174
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0280207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6484850003OtherMEDICARE NSC - EFFECT 02/01/2011
TX8B7873OtherBLUE CROSS BLUE SHIELD
TX8CR163OtherBCBS TX 02/01/2011
TXP00935338OtherRAILROAD MEDICARE
TXTXB126769OtherMEDICARE PART B - EFFECT. 4-20-11
TX123405606Medicaid
TXP00935338OtherRAILROAD MEDICARE
TX123405606Medicaid
TXB27531Medicare UPIN
TX4375780002Medicare NSC