Provider Demographics
NPI:1295848216
Name:GLEASON, THEODORE J (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:J
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 1:111 OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-1853
Mailing Address - Country:US
Mailing Address - Phone:309-740-4272
Mailing Address - Fax:
Practice Address - Street 1:800 E CARPENTER ST
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5324
Practice Address - Country:US
Practice Address - Phone:217-544-6464
Practice Address - Fax:217-525-5671
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL360825522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL300026084OtherRR MEDICARE
ILP00028344OtherRR MEDICARE
ILP00028344OtherRR MEDICARE
ILL73432Medicare PIN
ILL19224Medicare PIN