Basic Information
| Provider Information | |||||||||
| NPI: | 1104848811 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLADSTEIN | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 ZECKENDORF BLVD | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115302133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165426880 | ||||||||
| FaxNumber: | 5165425556 | ||||||||
| Practice Location | |||||||||
| Address1: | 640 HAWKINS AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE RONKONKOMA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117792324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317370100 | ||||||||
| FaxNumber: | 6314171117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 06/22/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 143678 | NY | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.