Individual
GLEN A. MEDELLIN
Active
Individual
GLEN A. MEDELLIN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
K3796
TX
2080H0002X
Pediatric Hospice and Palliative Medicine Physician
Primary
K3796
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
125095307
CSHCN
TX
05
—
125095307
—
TX
05
—
125095308
—
TX
01
—
125095309
MEDICAID CSHCN
TX
Enumeration date
08/11/2006
Last updated
09/19/2024
Update your record
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