1649763541 NPI number — ROLAND T GLENISTER DO

Table of content: ROLAND T GLENISTER DO (NPI 1649763541)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649763541 NPI number — ROLAND T GLENISTER DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLENISTER
Provider First Name:
ROLAND
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649763541
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1631 11TH STREET
Provider Second Line Business Mailing Address:
UNIT B
Provider Business Mailing Address City Name:
WICHITA FALLS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76301-4332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-263-3000
Provider Business Mailing Address Fax Number:
940-263-3018

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1631 11TH STREET
Provider Second Line Business Practice Location Address:
UNIT B
Provider Business Practice Location Address City Name:
WICHITA FALLS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76301-4332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-263-3000
Provider Business Practice Location Address Fax Number:
940-263-3018
Provider Enumeration Date:
06/14/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  S3905 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: S3905 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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