Provider Demographics
NPI:1750325536
Name:GLEASON, WALLACE A (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:A
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 301173
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75303-1173
Mailing Address - Country:US
Mailing Address - Phone:713-500-3500
Mailing Address - Fax:
Practice Address - Street 1:6410 FANNIN ST
Practice Address - Street 2:500
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3000
Practice Address - Country:US
Practice Address - Phone:832-325-7111
Practice Address - Fax:713-512-2230
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE96592080P0206X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137015705OtherCSHCN
TX88Y666OtherBCBS
TX137015708Medicaid
TX137015705OtherCSHCN
TX88Y666OtherBCBS
TXC16159Medicare UPIN
TX137015708Medicaid