Provider Demographics
NPI:1154416931
Name:CLICK, C. GLEN (MD)
Entity type:Individual
Prefix:DR
First Name:C.
Middle Name:GLEN
Last Name:CLICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 PORTMAN AVE
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:KY
Mailing Address - Zip Code:40484-1230
Mailing Address - Country:US
Mailing Address - Phone:606-365-9181
Mailing Address - Fax:606-365-9183
Practice Address - Street 1:126 PORTMAN AVE
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:KY
Practice Address - Zip Code:40484-1230
Practice Address - Country:US
Practice Address - Phone:606-365-9181
Practice Address - Fax:606-365-9183
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17220207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64-172208Medicaid
KYD92464Medicare UPIN
KY64-172208Medicaid