Provider Demographics
NPI:1780685768
Name:GLADD, JEFFREY E (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:E
Last Name:GLADD
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 1:10515 ILLINOIS RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-9182
Mailing Address - Country:US
Mailing Address - Phone:260-373-9233
Mailing Address - Fax:260-373-9219
Practice Address - Street 1:1234 E DUPONT RD
Practice Address - Street 2:SUITE 3
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1545
Practice Address - Country:US
Practice Address - Phone:260-373-9965
Practice Address - Fax:260-458-5664
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2009-09-22
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
IN01056652207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000346257OtherANTHEM
IN351972384039OtherTRICARE
IN7059457OtherAETNA
IN15705OtherPHP
IN000000570551OtherANTHEM
IN8194415OtherCIGNA
IN200488620AMedicaid
INP00334586OtherRAILROAD MEDICARE
IN070900 TMedicare PIN
IN070860NNNMedicare PIN
IN351972384039OtherTRICARE
IN200488620AMedicaid
IN15705OtherPHP