Healthcare Provider Details

I. General information

NPI: 1184674061
Provider Name (Legal Business Name): MARK GLADSTEIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2076 E 13TH ST
BROOKLYN NY
11229-3304
US

IV. Provider business mailing address

2076 E 13TH ST
BROOKLYN NY
11229-3304
US

V. Phone/Fax

Practice location:
  • Phone: 718-382-7900
  • Fax: 718-382-7901
Mailing address:
  • Phone: 718-382-7900
  • Fax: 718-382-7901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number205366
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number205366
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: