Healthcare Provider Details

I. General information

NPI: 1912149790
Provider Name (Legal Business Name): SAMUEL R. GLICKMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2009
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 GENESEE AVE STE 370
LA JOLLA CA
92037-1212
US

IV. Provider business mailing address

9850 GENESEE AVE STE 370
LA JOLLA CA
92037-1212
US

V. Phone/Fax

Practice location:
  • Phone: 858-625-7200
  • Fax: 858-625-8363
Mailing address:
  • Phone: 858-625-7200
  • Fax: 858-625-8363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA158303
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA158303
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: