Provider Demographics
NPI:1164957098
Name:GLEASON, AUGUSTUS (MD)
Entity Type:Individual
Prefix:
First Name:AUGUSTUS
Middle Name:
Last Name:GLEASON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 555191
Mailing Address - Street 2:
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055-5191
Mailing Address - Country:US
Mailing Address - Phone:760-725-1356
Mailing Address - Fax:
Practice Address - Street 1:200 MERCY CIRCLE
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-725-1356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA191356208600000X
MA208600000X208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty