Healthcare Provider Details

I. General information

NPI: 1134126832
Provider Name (Legal Business Name): JEFFREY L GLICKMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SE OSCEOLA ST STE 200
STUART FL
34994-2364
US

IV. Provider business mailing address

PO BOX 417
STUART FL
34995-0417
US

V. Phone/Fax

Practice location:
  • Phone: 772-286-1550
  • Fax: 772-221-0569
Mailing address:
  • Phone: 772-223-5665
  • Fax: 772-223-5646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number46721
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: