Provider Demographics
NPI:1255318622
Name:GLADSTONE, ALFRED G (MD)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:G
Last Name:GLADSTONE
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:PO BOX 217
Mailing Address - Street 2:1 LIBERTY SQUARE
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06050-0217
Mailing Address - Country:US
Mailing Address - Phone:860-827-0071
Mailing Address - Fax:860-229-5642
Practice Address - Street 1:100 GRAND ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06050
Practice Address - Country:US
Practice Address - Phone:860-224-5556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0253542085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001253541Medicaid
CT0300000459Medicare NSC
CT001253541Medicaid
300119097Medicare PIN