Provider Demographics
NPI:1376670729
Name:GLADSTONE, LEONARD GARY (MD)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:GARY
Last Name:GLADSTONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:L
Other - Middle Name:GARY
Other - Last Name:GLADSTONE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1263 GEORGIA LN
Mailing Address - Street 2:
Mailing Address - City:HATFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:19440-3227
Mailing Address - Country:US
Mailing Address - Phone:215-808-1212
Mailing Address - Fax:215-855-1048
Practice Address - Street 1:1263 GEORGIA LN
Practice Address - Street 2:
Practice Address - City:HATFIELD
Practice Address - State:PA
Practice Address - Zip Code:19440-3227
Practice Address - Country:US
Practice Address - Phone:215-808-1212
Practice Address - Fax:215-855-1048
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD016541E207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC28982Medicare UPIN
PA029865Medicare PIN