Provider Demographics
NPI:1043919558
Name:GLOSTER, TED JR
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:GLOSTER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2436 HAZELWOOD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48206-2244
Mailing Address - Country:US
Mailing Address - Phone:313-346-3761
Mailing Address - Fax:
Practice Address - Street 1:2436 HAZELWOOD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48206-2244
Practice Address - Country:US
Practice Address - Phone:313-346-3761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIG423789004993171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor