Provider Demographics
NPI:1679557177
Name:GLICK, DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:GLICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5710
Mailing Address - Country:US
Mailing Address - Phone:314-391-9777
Mailing Address - Fax:314-390-5404
Practice Address - Street 1:175 N OAKS PLZ
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-2925
Practice Address - Country:US
Practice Address - Phone:314-391-9777
Practice Address - Fax:314-390-5404
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2021-10-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO112861207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO20497110Medicaid
MO204977102Medicaid
MO047010581OtherCPIN
MO20497110Medicaid