Provider Demographics
NPI:1598703654
Name:GLUCKSTEIN, DANIEL PETER (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:PETER
Last Name:GLUCKSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:310 N INDIAN HILL BLVD
Mailing Address - Street 2:PMB # 801
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-4611
Mailing Address - Country:US
Mailing Address - Phone:909-275-7470
Mailing Address - Fax:909-971-4532
Practice Address - Street 1:255 E BONITA AVE BLDG 1B
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1923
Practice Address - Country:US
Practice Address - Phone:909-275-7470
Practice Address - Fax:909-971-4532
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG56964207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG569640OtherCA STATE LICENSE #
WG56964BOtherMEDICARE SO CAL PTAN
CAGR0059670Medicaid
CA00G569640Medicaid
BK904ZOtherMEDICARE NO CAL PTAN
BK904ZOtherMEDICARE NO CAL PTAN