Healthcare Provider Details

I. General information

NPI: 1376506386
Provider Name (Legal Business Name): TODD M GLADSTONE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1095 W MAIN ST
NEW BRITAIN CT
06053-3454
US

IV. Provider business mailing address

1095 W MAIN ST
NEW BRITAIN CT
06053-3454
US

V. Phone/Fax

Practice location:
  • Phone: 860-225-6064
  • Fax: 860-229-1072
Mailing address:
  • Phone: 860-225-6064
  • Fax: 860-229-1072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number16253
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: