Provider Demographics
NPI:1417975996
Name:GLICKMAN, BRUCE STEVEN (DC)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:STEVEN
Last Name:GLICKMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464073 SR 200
Mailing Address - Street 2:SUITE 4
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097
Mailing Address - Country:US
Mailing Address - Phone:904-491-1345
Mailing Address - Fax:904-491-1346
Practice Address - Street 1:464073 SR 200
Practice Address - Street 2:SUITE 4
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097
Practice Address - Country:US
Practice Address - Phone:904-491-1345
Practice Address - Fax:904-491-1346
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3341111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381329100Medicaid
FL88503Medicare ID - Type Unspecified
FL381329100Medicaid