Provider Demographics
NPI:1235134412
Name:GLICK, RONALD M (DO)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:M
Last Name:GLICK
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 1:3940 E UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-6945
Mailing Address - Country:US
Mailing Address - Phone:480-924-9235
Mailing Address - Fax:480-832-5501
Practice Address - Street 1:3940 E UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-6945
Practice Address - Country:US
Practice Address - Phone:480-924-9235
Practice Address - Fax:480-832-5501
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2012207NS0135X, 207N00000X, 207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ278938Medicaid
AZE20688Medicare UPIN
AZ118023Medicare PIN