Provider Demographics
NPI:1376506386
Name:GLADSTONE, TODD M (MD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:M
Last Name:GLADSTONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1095 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06053-3454
Mailing Address - Country:US
Mailing Address - Phone:860-225-6064
Mailing Address - Fax:860-229-1072
Practice Address - Street 1:1095 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06053-3454
Practice Address - Country:US
Practice Address - Phone:860-225-6064
Practice Address - Fax:860-229-1072
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT16253173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTR00039Medicare UPIN