Provider Demographics
NPI:1104848811
Name:GLADSTEIN, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GLADSTEIN
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 1:1000 ZECKENDORF BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-2133
Mailing Address - Country:US
Mailing Address - Phone:516-542-6880
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:640 HAWKINS AVE
Practice Address - Street 2:
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-2324
Practice Address - Country:US
Practice Address - Phone:631-737-0100
Practice Address - Fax:631-417-1117
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143678207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB88904Medicare UPIN
NY90D463Medicare ID - Type Unspecified