Provider Demographics
NPI:1598820557
Name:GLEASON, CHARLES KERRY (DC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:KERRY
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 1:438 HALEDON AVENUE
Mailing Address - Street 2:
Mailing Address - City:HALEDON
Mailing Address - State:NJ
Mailing Address - Zip Code:07508
Mailing Address - Country:US
Mailing Address - Phone:973-956-5700
Mailing Address - Fax:973-956-7800
Practice Address - Street 1:438 HALEDON AVENUE
Practice Address - Street 2:
Practice Address - City:HALEDON
Practice Address - State:NJ
Practice Address - Zip Code:07508
Practice Address - Country:US
Practice Address - Phone:973-956-5700
Practice Address - Fax:973-956-7800
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC00525400111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U73130Medicare UPIN
NJGW22045Medicare ID - Type Unspecified