Healthcare Provider Details

I. General information

NPI: 1235134412
Provider Name (Legal Business Name): RONALD M GLICK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3940 E UNIVERSITY DR
MESA AZ
85205-6945
US

IV. Provider business mailing address

3940 E UNIVERSITY DR
MESA AZ
85205-6945
US

V. Phone/Fax

Practice location:
  • Phone: 480-924-9235
  • Fax: 480-832-5501
Mailing address:
  • Phone: 480-924-9235
  • Fax: 480-832-5501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number2012
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2012
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number2012
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier278938
Identifier TypeMEDICAID
Identifier StateAZ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: