Provider Demographics
NPI:1023045333
Name:GLICKMAN, JONATHAN NEIL (MD, PHD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:NEIL
Last Name:GLICKMAN
Suffix:
Gender:M
Credentials:MD, PHD
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 840294
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0294
Mailing Address - Country:US
Mailing Address - Phone:888-344-1160
Mailing Address - Fax:972-331-3148
Practice Address - Street 1:320 NEEDHAM STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02464
Practice Address - Country:US
Practice Address - Phone:617-969-4100
Practice Address - Fax:617-969-3393
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA158613207ZP0101X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3196046Medicaid
MA3196046Medicaid