Provider Demographics
NPI:1770589798
Name:GLAZE, ANDREW G (DC)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:G
Last Name:GLAZE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 949
Mailing Address - Street 2:
Mailing Address - City:GILMER
Mailing Address - State:TX
Mailing Address - Zip Code:75644-0949
Mailing Address - Country:US
Mailing Address - Phone:903-843-5673
Mailing Address - Fax:
Practice Address - Street 1:1026 TITUS ST
Practice Address - Street 2:
Practice Address - City:GILMER
Practice Address - State:TX
Practice Address - Zip Code:75644-3514
Practice Address - Country:US
Practice Address - Phone:803-843-5643
Practice Address - Fax:903-843-4403
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC5316111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8214226OtherBCBS
80180GMedicare ID - Type Unspecified
U14226Medicare UPIN