Provider Demographics
NPI:1184693749
Name:HARDESTY, GLENN (DO)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:HARDESTY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 960160
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73196-0001
Mailing Address - Country:US
Mailing Address - Phone:877-485-4474
Mailing Address - Fax:
Practice Address - Street 1:800 W RANDOL MILL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-2504
Practice Address - Country:US
Practice Address - Phone:817-548-6202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8201207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX88778ZOtherBCBS THRU AEMA
TX029651902Medicaid
TX8BT321OtherBCBS THRU SAEMA
TX930124542OtherRAILROAD THRU AEMA
TXP01207143OtherRAILROAD MCARE
TX029651903Medicaid
TX8F9883Medicare PIN
TX029651902Medicaid
TX029651903Medicaid