Healthcare Provider Details

I. General information

NPI: 1417534009
Provider Name (Legal Business Name): SAMUEL GLICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2021
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 UCLA MEDICAL PLZ STE 265
LOS ANGELES CA
90095-8358
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-0867
  • Fax: 310-794-5066
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA195032
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: