Provider Demographics
NPI:1629070370
Name:GLUCKMAN, JERRY PAUL (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:PAUL
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 1:1403 FOULK RD
Mailing Address - Street 2:STE 105
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803-2788
Mailing Address - Country:US
Mailing Address - Phone:302-479-0100
Mailing Address - Fax:302-479-0177
Practice Address - Street 1:1403 FOULK RD STE 105
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-4054
Practice Address - Country:US
Practice Address - Phone:302-479-0100
Practice Address - Fax:302-479-0177
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10002836207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B66552Medicare UPIN
000164941Medicare ID - Type Unspecified