Provider Demographics
NPI:1770503740
Name:GLEASMAN, DOUGLAS WAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:WAYNE
Last Name:GLEASMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 UTICA ROAD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NY
Mailing Address - Zip Code:13323
Mailing Address - Country:US
Mailing Address - Phone:315-853-4000
Mailing Address - Fax:315-853-4000
Practice Address - Street 1:129 UTICA RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-1516
Practice Address - Country:US
Practice Address - Phone:315-853-4000
Practice Address - Fax:315-853-4000
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX007257-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY54151BMedicare ID - Type Unspecified