Healthcare Provider Details

I. General information

NPI: 1275630667
Provider Name (Legal Business Name): CHARLES JONATHAN GLUECK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2135 DANA AVE SUITE 430
CINCINNATI OH
45207-1313
US

IV. Provider business mailing address

2135 DANA AVE SUITE 430
CINCINNATI OH
45207-1313
US

V. Phone/Fax

Practice location:
  • Phone: 513-924-8250
  • Fax: 513-924-8272
Mailing address:
  • Phone: 513-924-8250
  • Fax: 513-924-8272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number35.027629
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: