1780685768 NPI number — DR. JEFFREY E GLADD M.D.

Table of content: DR. JEFFREY E GLADD M.D. (NPI 1780685768)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780685768 NPI number — DR. JEFFREY E GLADD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLADD
Provider First Name:
JEFFREY
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780685768
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/21/2006
NPI Reactivation Date:
03/30/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10515 ILLINOIS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46814-9182
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-373-9233
Provider Business Mailing Address Fax Number:
260-373-9219

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1234 E DUPONT RD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46825-1545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-373-9965
Provider Business Practice Location Address Fax Number:
260-458-5664
Provider Enumeration Date:
08/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  01056652 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000346257 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 351972384039 . This is a "TRICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 7059457 . This is a "AETNA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 15705 . This is a "PHP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000570551 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 8194415 . This is a "CIGNA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200488620A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00334586 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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