Provider Demographics
NPI:1497781181
Name:GLICKMAN, JAY (DO)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:GLICKMAN
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 1:3790 MORRELL AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-1955
Mailing Address - Country:US
Mailing Address - Phone:215-612-1450
Mailing Address - Fax:215-612-1420
Practice Address - Street 1:3790 MORRELL AVE
Practice Address - Street 2:SUITE B
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1955
Practice Address - Country:US
Practice Address - Phone:215-612-1450
Practice Address - Fax:215-612-1420
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS 009194-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAGL001406Medicare ID - Type Unspecified
PAG58837Medicare UPIN