Provider Demographics
NPI:1477533511
Name:GLICK, JEFFREY A (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:GLICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5805 SEPULVEDA BLVD
Mailing Address - Street 2:SUITE 610
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-2546
Mailing Address - Country:US
Mailing Address - Phone:818-908-8048
Mailing Address - Fax:818-908-8072
Practice Address - Street 1:12660 RIVERSIDE DR
Practice Address - Street 2:SUITE 225
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91607-3429
Practice Address - Country:US
Practice Address - Phone:818-487-0040
Practice Address - Fax:818-487-0050
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2017-09-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG58181207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G581810Medicaid
CAWG58181AMedicare PIN
CAE50618Medicare UPIN