Provider Demographics
NPI:1689758211
Name:GLICKSTEEN, GARY ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ALAN
Last Name:GLICKSTEEN
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 1:8614 BAYMEADOWS WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-8236
Mailing Address - Country:US
Mailing Address - Phone:904-396-0450
Mailing Address - Fax:904-346-0212
Practice Address - Street 1:8614 BAYMEADOWS WAY STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-8236
Practice Address - Country:US
Practice Address - Phone:904-396-0450
Practice Address - Fax:904-346-0212
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74520207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01028954OtherRAILROAD MEDICARE
FL42487YMedicare PIN
FLP01028954OtherRAILROAD MEDICARE
FL269183300Medicaid