Provider Demographics
NPI:1598837957
Name:BLICK, GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:BLICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2595 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06615-5855
Mailing Address - Country:US
Mailing Address - Phone:203-345-0404
Mailing Address - Fax:203-908-4110
Practice Address - Street 1:2595 MAIN ST
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-5855
Practice Address - Country:US
Practice Address - Phone:203-345-0404
Practice Address - Fax:203-908-4110
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT027524207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001275247Medicaid
NY02555264Medicaid
CT110008585Medicare PIN
NY02555264Medicaid
CTD100053491Medicare PIN