Healthcare Provider Details

I. General information

NPI: 1104848811
Provider Name (Legal Business Name): MICHAEL GLADSTEIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 HAWKINS AVE
LAKE RONKONKOMA NY
11779-2324
US

IV. Provider business mailing address

2792 OCEAN AVE FL 2
BROOKLYN NY
11229-4731
US

V. Phone/Fax

Practice location:
  • Phone: 631-737-0100
  • Fax: 631-417-1117
Mailing address:
  • Phone: 833-635-2566
  • Fax: 833-635-2566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number143678
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: