Provider Demographics
NPI:1336288943
Name:GLUCKMAN, RICHARD S (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:S
Last Name:GLUCKMAN
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 1:1360 W 6TH ST
Mailing Address - Street 2:#350, NORTH BLDG
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3514
Mailing Address - Country:US
Mailing Address - Phone:310-832-6428
Mailing Address - Fax:310-832-5178
Practice Address - Street 1:1360 W 6TH ST
Practice Address - Street 2:#350, NORTH BLDG
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3514
Practice Address - Country:US
Practice Address - Phone:310-832-6428
Practice Address - Fax:310-832-5178
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG338912084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA45714Medicare UPIN
CAG33891Medicare PIN