Provider Demographics
NPI:1144300674
Name:GLASS, JEFFREY (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:GLASS
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 1:12810 HILLCREST RD
Mailing Address - Street 2:SUITE B220
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-1525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12810 HILLCREST RD
Practice Address - Street 2:SUITE B220
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-1525
Practice Address - Country:US
Practice Address - Phone:214-696-9270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG42982084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1002735-01Medicaid
TXC16146Medicare UPIN