Provider Demographics
NPI:1861439051
Name:MCCRELESS, GLEN D
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:D
Last Name:MCCRELESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4037 E SOUTHCROSS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78222-3636
Mailing Address - Country:US
Mailing Address - Phone:210-337-4921
Mailing Address - Fax:210-337-7297
Practice Address - Street 1:4037 E SOUTHCROSS BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78222-3636
Practice Address - Country:US
Practice Address - Phone:210-337-4921
Practice Address - Fax:210-337-7297
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9798207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX033364301Medicaid
TXB24722Medicare UPIN
TX033364301Medicaid