Provider Demographics
NPI:1982634499
Name:GLADSTONE, GEOFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:GEOFFREY
Middle Name:
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 1:29201 TELEGRAPH RD
Mailing Address - Street 2:SUITE 324
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1331
Mailing Address - Country:US
Mailing Address - Phone:248-357-5100
Mailing Address - Fax:248-746-0683
Practice Address - Street 1:29201 TELEGRAPH RD
Practice Address - Street 2:SUITE 324
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1331
Practice Address - Country:US
Practice Address - Phone:248-357-5100
Practice Address - Fax:248-746-0683
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301041157207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4361207-10Medicaid
MIB46363Medicare UPIN
N52410005Medicare ID - Type Unspecified