Provider Demographics
NPI:1811904337
Name:GLICK, JOHN EDWARD (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:GLICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2908 HILLRISE DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4702
Mailing Address - Country:US
Mailing Address - Phone:505-522-5222
Mailing Address - Fax:505-522-5223
Practice Address - Street 1:271 PASEO DE DIA # 1A
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-7341
Practice Address - Country:US
Practice Address - Phone:575-323-6500
Practice Address - Fax:575-323-6501
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2022-10-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NMNM 79-164207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine