Provider Demographics
NPI:1134188220
Name:GLADSTONE, SAMUEL (MD)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
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 1:12 DICKINSON ST
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:MA
Mailing Address - Zip Code:01002-2310
Mailing Address - Country:US
Mailing Address - Phone:413-253-2300
Mailing Address - Fax:413-256-0464
Practice Address - Street 1:12 DICKINSON ST
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:MA
Practice Address - Zip Code:01002-2310
Practice Address - Country:US
Practice Address - Phone:413-253-2300
Practice Address - Fax:413-256-0464
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA55035207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2358324OtherAETNA
MA706042OtherCONNECTICARE
MA3029671Medicaid
MA71777OtherHARVARD PILGRIM
MA10248501OtherCIGNA
MAJ06871OtherBCBSMA
MA720950OtherTUFTS
MA000000007610OtherBMC
MA12640OtherHNE
MAJ06871Medicare PIN
MA000000007610OtherBMC