Basic Information
| Provider Information | |||||||||
| NPI: | 1780685768 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLADD | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10515 ILLINOIS RD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468149182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739233 | ||||||||
| FaxNumber: | 2603739219 | ||||||||
| Practice Location | |||||||||
| Address1: | 1234 E DUPONT RD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739965 | ||||||||
| FaxNumber: | 2604585664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 09/22/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/21/2006 | ||||||||
| NPIReactivationDate: | 03/30/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01056652 | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000346257 | 01 | IN | ANTHEM | OTHER | 351972384039 | 01 | IN | TRICARE | OTHER | 7059457 | 01 | IN | AETNA | OTHER | 15705 | 01 | IN | PHP | OTHER | 000000570551 | 01 | IN | ANTHEM | OTHER | 8194415 | 01 | IN | CIGNA | OTHER | 200488620A | 05 | IN | MEDICAID | P00334586 | 01 | IN | RAILROAD MEDICARE | OTHER |