Provider Demographics
NPI:1114288214
Name:GLICK, JAIMIE BROOKE (MD)
Entity Type:Individual
Prefix:
First Name:JAIMIE
Middle Name:BROOKE
Last Name:GLICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 5TH AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-1007
Mailing Address - Country:US
Mailing Address - Phone:212-533-8888
Mailing Address - Fax:
Practice Address - Street 1:119 5TH AVE FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-1007
Practice Address - Country:US
Practice Address - Phone:212-533-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY282751207N00000X
PAMT202087390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology