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General NPI Number Information
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NPI Number | 1174518773
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Entity Type | Individual
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Provider Name | LAWRENCE GLUCK MD
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Gender | Male
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Dates
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Enumeration Date | 09/20/2005
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Last Update Date | 07/30/2007
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Provider Practice Location Address
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Address Line | 130 DIVISION ST
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City | DERBY
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State | CT
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Zip | 06418-1326
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Country | US
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Telephone | 203-735-8769
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 8416
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City | NEW HAVEN
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State | CT
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Zip | 06530-0416
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Country | US
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Telephone | 203-777-6209
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Fax | 203-787-2431
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 017422
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License Number State | CT
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