Provider Demographics
NPI:1881670636
Name:GLOCK, RICHARD D (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:D
Last Name:GLOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:8614 BAYMEADOWS WAY
Mailing Address - Street 2:#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
Practice Address - Street 2:#100
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:2005-12-22
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0023128207R00000X
FLME23128207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD53122Medicare UPIN
D53122Medicare UPIN
16979YMedicare PIN