Provider Demographics
NPI:1164401063
Name:BEALE, GLADYS A (MD)
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:A
Last Name:BEALE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GLADYS
Other - Middle Name:A
Other - Last Name:BEALE-GANZHORN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:260-266-6013
Mailing Address - Fax:
Practice Address - Street 1:1720 BEACON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4749
Practice Address - Country:US
Practice Address - Phone:260-373-8000
Practice Address - Fax:260-373-8034
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052426A2084P0804X, 2084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000543920OtherANTHEM
OH2566067Medicaid
IN200274420Medicaid
260043528OtherRAILROAD MEDICARE
INP00466953OtherRAILROAD MEDICARE
E73305Medicare UPIN
IN000000543920OtherANTHEM
OH2566067Medicaid