Healthcare Provider Details

I. General information

NPI: 1851363097
Provider Name (Legal Business Name): MEREDITH GLICKMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 AVENIDA DE LOS ARBOLES #201
THOUSAND OAKS CA
91360-3003
US

IV. Provider business mailing address

430 AVENIDA DE LOS ARBOLES #201
THOUSAND OAKS CA
91360-3003
US

V. Phone/Fax

Practice location:
  • Phone: 805-493-1964
  • Fax: 805-492-0614
Mailing address:
  • Phone: 805-493-1964
  • Fax: 805-492-0614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA061852
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: