Provider Demographics
NPI:1104155100
Name:GLUCKSMAN, EARL GORDON (PT)
Entity type:Individual
Prefix:MR
First Name:EARL
Middle Name:GORDON
Last Name:GLUCKSMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MARCY CT
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1942
Mailing Address - Country:US
Mailing Address - Phone:631-689-1678
Mailing Address - Fax:631-689-1678
Practice Address - Street 1:1 MARCY CT
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-1942
Practice Address - Country:US
Practice Address - Phone:631-689-1678
Practice Address - Fax:631-689-1678
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-22
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6121225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist