MEDICARE: DR. RONALD M GLICK D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207NS0135X	Procedural Dermatology Physician	2012	AZ
2	207N00000X	Dermatology Physician	2012	AZ
3	207NP0225X	Pediatric Dermatology Physician	2012	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235134412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RONALD M GLICK D.O.

Provider Business Mailing Address
First Line	:	3940 E UNIVERSITY DR
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85205-6945
Country	:	US
Telephone Number	:	480-924-9235
Fax Number	:	480-832-5501

Provider Business Practice Location Address
First Line	:	3940 E UNIVERSITY DR
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85205-6945
Country	:	US
Telephone Number	:	480-924-9235
Fax Number	:	480-832-5501

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	02/09/2022

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Directions to “ DR. RONALD M GLICK D.O.” Practice Location

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