Provider Demographics
NPI:1952892622
Name:GLADSTEIN, LEONID
Entity Type:Individual
Prefix:
First Name:LEONID
Middle Name:
Last Name:GLADSTEIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 COMMACK RD STE 2B
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-4508
Mailing Address - Country:US
Mailing Address - Phone:917-887-8872
Mailing Address - Fax:
Practice Address - Street 1:409 COMMACK RD STE 2B
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-4508
Practice Address - Country:US
Practice Address - Phone:917-887-8872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006983156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY006983Medicaid