Provider Demographics
NPI:1891231825
Name:GLICKSTEIN, ANDREW MARK (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:MARK
Last Name:GLICKSTEIN
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 1:4665 BUSINESS CENTER DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-1675
Mailing Address - Country:US
Mailing Address - Phone:707-863-4258
Mailing Address - Fax:
Practice Address - Street 1:4665 BUSINESS CENTER DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-1675
Practice Address - Country:US
Practice Address - Phone:707-863-4258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-14
Last Update Date:2017-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25783207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine