Provider Demographics
NPI:1821029166
Name:GLICK, JOHN L (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:GLICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-7109
Mailing Address - Country:US
Mailing Address - Phone:802-254-9240
Mailing Address - Fax:802-257-8654
Practice Address - Street 1:19 BELMONT AVE STE 1205
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-4004
Practice Address - Country:US
Practice Address - Phone:802-254-9240
Practice Address - Fax:802-257-8654
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VT0420003993207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTVT4335Medicaid
VTVT4335Medicaid