Provider Demographics
NPI:1295696789
Name:GLOUDEMAN, MICHAEL JAMES
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:GLOUDEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18092 SONOMA HWY UNIT 1546
Mailing Address - Street 2:
Mailing Address - City:BOYES HOT SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95416-8940
Mailing Address - Country:US
Mailing Address - Phone:707-718-2070
Mailing Address - Fax:
Practice Address - Street 1:18092 SONOMA HWY UNIT 1546
Practice Address - Street 2:
Practice Address - City:BOYES HOT SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95416-8940
Practice Address - Country:US
Practice Address - Phone:707-718-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-24
Last Update Date:2025-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAINT45476390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program