Provider Demographics
NPI:1093872145
Name:GLICK, GARY LEWIS (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEWIS
Last Name:GLICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4308 ALTON RD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33140-4556
Mailing Address - Country:US
Mailing Address - Phone:305-672-6100
Mailing Address - Fax:305-532-7444
Practice Address - Street 1:4308 ALTON RD
Practice Address - Street 2:SUITE 410
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-4556
Practice Address - Country:US
Practice Address - Phone:305-672-6100
Practice Address - Fax:305-532-7444
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2009-01-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME0066644208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL25398WMedicare PIN
FLF83689Medicare UPIN