Provider Demographics
NPI:1437187283
Name:GLADSTONE, ADAM DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:DOUGLAS
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 1:2110 DORCHESTER AVE
Mailing Address - Street 2:#203
Mailing Address - City:DORCHESTER CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-5628
Mailing Address - Country:US
Mailing Address - Phone:617-296-4951
Mailing Address - Fax:617-298-7389
Practice Address - Street 1:2110 DORCHESTER AVE
Practice Address - Street 2:#203
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-5628
Practice Address - Country:US
Practice Address - Phone:617-296-4951
Practice Address - Fax:617-298-7389
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA158773207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
J21732OtherBLUE CROSS BLUE SHEILD
0406652OtherUNITED HEALTH CARE
69869OtherHARVARD PILGRIM HEALTH CA
MA0110221Medicaid
B10418301OtherCIGNA
158773OtherTUFTS HEALTH PLAN ID
A29938Medicare UPIN