Provider Demographics
NPI:1477621688
Name:GLEASON, ROBERT E (DC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:GLEASON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:SHIP BOTTOM
Mailing Address - State:NJ
Mailing Address - Zip Code:08008-4474
Mailing Address - Country:US
Mailing Address - Phone:609-494-5757
Mailing Address - Fax:609-494-5147
Practice Address - Street 1:111 W 15TH ST
Practice Address - Street 2:
Practice Address - City:SHIP BOTTOM
Practice Address - State:NJ
Practice Address - Zip Code:08008-4474
Practice Address - Country:US
Practice Address - Phone:609-494-5757
Practice Address - Fax:609-494-5147
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC04553111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ486447Medicare PIN