Provider Demographics
NPI:1386605731
Name:RICHARD S. GLUCKMAN M.D. INC
Entity type:Organization
Organization Name:RICHARD S. GLUCKMAN M.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:GLUCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-832-6428
Mailing Address - Street 1:1360 W 6TH ST
Mailing Address - Street 2:#350
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3514
Mailing Address - Country:US
Mailing Address - Phone:310-832-6428
Mailing Address - Fax:310-832-5178
Practice Address - Street 1:1360 W 6TH ST
Practice Address - Street 2:#350
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3514
Practice Address - Country:US
Practice Address - Phone:310-832-6428
Practice Address - Fax:310-832-5178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG338912084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA45714Medicare UPIN
CAG33891Medicare ID - Type Unspecified