Provider Demographics
NPI:1316980055
Name:GLADSTONE, IRWIN S (OD)
Entity type:Individual
Prefix:
First Name:IRWIN
Middle Name:S
Last Name:GLADSTONE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4802 NESHAMINY BLVD
Mailing Address - Street 2:
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-1041
Mailing Address - Country:US
Mailing Address - Phone:215-757-7871
Mailing Address - Fax:215-757-3319
Practice Address - Street 1:4802 NESHAMINY BLVD
Practice Address - Street 2:SUITE 7
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-1041
Practice Address - Country:US
Practice Address - Phone:215-757-7871
Practice Address - Fax:215-757-3319
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG 000779152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0179670001Medicare NSC
PAU08028Medicare UPIN
PA287918Medicare PIN