Healthcare Provider Details

I. General information

NPI: 1679693428
Provider Name (Legal Business Name): SCOTT GARY GLICKMAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6850 N DURANGO DR STE 301
LAS VEGAS NV
89149-4597
US

IV. Provider business mailing address

42 BUSINESS CENTRE DR UNIT 310
MIRAMAR BEACH FL
32550-6995
US

V. Phone/Fax

Practice location:
  • Phone: 702-929-8242
  • Fax: 702-553-3242
Mailing address:
  • Phone: 850-803-2672
  • Fax: 850-600-2672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number02003330A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberDR.0057671
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number13826
License Number StateND
# 4
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number13305
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberDO2209
License Number StateNV
# 6
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number036118927
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: