Healthcare Provider Details

I. General information

NPI: 1780645010
Provider Name (Legal Business Name): KEITH L GLADSTIEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S ANAHEIM HILLS RD #140
ANAHEIM CA
92807-4780
US

IV. Provider business mailing address

500 S. ANAHEIM HILLS RD, #140
ANAHEIM HILLS CA
92807
US

V. Phone/Fax

Practice location:
  • Phone: 714-974-2220
  • Fax:
Mailing address:
  • Phone: 714-974-2220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG51949
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: