Provider Demographics
NPI:1013198050
Name:JAMES E. GLEASON JR, MDPC
Entity Type:Organization
Organization Name:JAMES E. GLEASON JR, MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:GLEASON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:770-994-6969
Mailing Address - Street 1:PO BOX 962466
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-6923
Mailing Address - Country:US
Mailing Address - Phone:678-361-8091
Mailing Address - Fax:888-651-5324
Practice Address - Street 1:33 UPPER RIVERDALE RD SW STE 118
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2642
Practice Address - Country:US
Practice Address - Phone:770-994-6969
Practice Address - Fax:888-651-5324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030466207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000573922DMedicaid