Basic Information
| Provider Information | |||||||||
| NPI: | 1174518773 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLUCK | ||||||||
| FirstName: | LAWRENCE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8416 | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065300416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037776209 | ||||||||
| FaxNumber: | 2037872431 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | DERBY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064181326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037358769 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 07/30/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 017422 | CT | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1174226 | 05 | CT | MEDICAID |