1023045333 NPI number — JONATHAN NEIL GLICKMAN M.D., PHD

Table of content: JONATHAN NEIL GLICKMAN M.D., PHD (NPI 1023045333)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023045333 NPI number — JONATHAN NEIL GLICKMAN M.D., PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLICKMAN
Provider First Name:
JONATHAN
Provider Middle Name:
NEIL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D., PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023045333
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 840294
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-0294
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-344-1160
Provider Business Mailing Address Fax Number:
972-331-3148

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 NEEDHAM STREET
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
NEWTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02464
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-969-4100
Provider Business Practice Location Address Fax Number:
617-969-3393
Provider Enumeration Date:
06/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0101X , with the licence number:  158613 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: 158613 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3196046 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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