Provider Demographics
NPI:1679693428
Name:GLICKMAN, SCOTT GARY (DO)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:GARY
Last Name:GLICKMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:42 BUSINESS CENTRE DR UNIT 310
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-6995
Mailing Address - Country:US
Mailing Address - Phone:850-803-2672
Mailing Address - Fax:850-600-2672
Practice Address - Street 1:6850 N DURANGO DR STE 301
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-4597
Practice Address - Country:US
Practice Address - Phone:702-929-8242
Practice Address - Fax:702-553-3242
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003330A207T00000X
CODR.0057671207T00000X, 207T00000X
ND13826207T00000X
CA13305207T00000X, 207T00000X
NVDO2209207T00000X
IL036118927207T00000X
SCDO36495207T00000X
OH34.009967207T00000X
MI5101015220207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1679693428Medicaid
OH3102403Medicaid