Basic Information
Provider Information
NPI: 1033559695
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GLICKMAN
FirstName: MICHAEL
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 130 SUTTER ST FL 2
Address2:  
City: SAN FRANCISCO
State: CA
PostalCode: 941044009
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 1350 CONNECTICUT AVE NW STE 1250
Address2:  
City: WASHINGTON
State: DC
PostalCode: 200361728
CountryCode: US
TelephoneNumber: 2026271901
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/27/2013
LastUpdateDate: 05/27/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000XMD044148DCY Allopathic & Osteopathic PhysiciansFamily Medicine 
207Q00000X0116025888VAN Allopathic & Osteopathic PhysiciansFamily Medicine 

No ID Information.


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