Provider Demographics
NPI:1760487599
Name:GLEICK, JEFFREY B (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:B
Last Name:GLEICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2912 SPRINGBORO RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1674
Mailing Address - Country:US
Mailing Address - Phone:937-297-8999
Mailing Address - Fax:937-298-9673
Practice Address - Street 1:1989 MIAMISBURG CENTERVILLE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-3859
Practice Address - Country:US
Practice Address - Phone:937-434-7353
Practice Address - Fax:937-438-6569
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35-067476207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00708877OtherRAILROAD MEDICARE
OH2065125Medicaid
GL4038173OtherPTAN
OH2065125Medicaid
GL4038173OtherPTAN