Provider Demographics
NPI:1740240126
Name:GLICKMAN M.D., GARY M
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:GLICKMAN M.D.
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-3801
Mailing Address - Country:US
Mailing Address - Phone:212-532-2500
Mailing Address - Fax:212-532-9689
Practice Address - Street 1:30 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-3801
Practice Address - Country:US
Practice Address - Phone:212-532-2500
Practice Address - Fax:212-532-9689
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY165722207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY165722OtherNY LICENSE
NY02046220Medicaid
NY01005201Medicaid
NYA64681Medicare UPIN
NYW34442Medicare ID - Type Unspecified
NYW34443Medicare ID - Type Unspecified
NY01005201Medicaid
NY165722OtherNY LICENSE
NY02046220Medicaid