Provider Demographics
NPI:1265529044
Name:SHICK, JON GLENN (DO LLC)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:GLENN
Last Name:SHICK
Suffix:
Gender:M
Credentials:DO LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7850 VANCE DR
Mailing Address - Street 2:#185
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80003
Mailing Address - Country:US
Mailing Address - Phone:303-423-0535
Mailing Address - Fax:303-422-3881
Practice Address - Street 1:7850 VANCE DR
Practice Address - Street 2:#185
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80003
Practice Address - Country:US
Practice Address - Phone:303-423-0535
Practice Address - Fax:303-422-3881
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39612207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO42004772Medicaid
H32305Medicare UPIN
CO528218Medicare ID - Type Unspecified