Provider Demographics
NPI:1811090442
Name:GLISKER, JUSTIN RICHARD (OD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:RICHARD
Last Name:GLISKER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 21ST STREET
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960
Mailing Address - Country:US
Mailing Address - Phone:772-562-2020
Mailing Address - Fax:772-562-5874
Practice Address - Street 1:530 21ST STREET
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960
Practice Address - Country:US
Practice Address - Phone:772-562-2020
Practice Address - Fax:772-562-5874
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3799152W00000X
NYTUV006880152W00000X
CT002663152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620846100Medicaid
U1452Medicare ID - Type Unspecified