Provider Demographics
NPI:1073697801
Name:GLADSTONE, NEIL S (MD)
Entity Type:Individual
Prefix:DR
First Name:NEIL
Middle Name:S
Last Name:GLADSTONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 962380
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-6921
Mailing Address - Country:US
Mailing Address - Phone:770-996-1200
Mailing Address - Fax:770-907-7492
Practice Address - Street 1:81 UPPER RIVERDALE RD
Practice Address - Street 2:SUITE 210
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2627
Practice Address - Country:US
Practice Address - Phone:770-996-1200
Practice Address - Fax:770-907-7492
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA016917207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00113759BMedicaid
GAD29569Medicare UPIN
GA2021162931Medicare PIN