Healthcare Provider Details

I. General information

NPI: 1093872145
Provider Name (Legal Business Name): GARY LEWIS GLICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2007
Last Update Date: 01/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4308 ALTON RD SUITE 410
MIAMI BEACH FL
33140-4556
US

IV. Provider business mailing address

4308 ALTON RD SUITE 410
MIAMI BEACH FL
33140-4556
US

V. Phone/Fax

Practice location:
  • Phone: 305-672-6100
  • Fax: 305-532-7444
Mailing address:
  • Phone: 305-672-6100
  • Fax: 305-532-7444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME0066644
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: