Provider Demographics
NPI:1649342007
Name:GLADSTONE, CHARLES M (DC)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:GLADSTONE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3333 BARDSTOWN RD
Mailing Address - Street 2:SUITE 11
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-4613
Mailing Address - Country:US
Mailing Address - Phone:502-451-9050
Mailing Address - Fax:502-451-9979
Practice Address - Street 1:3333 BARDSTOWN RD
Practice Address - Street 2:SUITE 11
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-4613
Practice Address - Country:US
Practice Address - Phone:502-451-9050
Practice Address - Fax:502-451-9979
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4279111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000042787OtherANTHEM BLUE CROSS PIN
U40112Medicare UPIN