Provider Demographics
NPI:1780649368
Name:GLEASON, JAMES E JR (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:E
Last Name:GLEASON
Suffix:JR
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 962466
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-6923
Mailing Address - Country:US
Mailing Address - Phone:770-994-6969
Mailing Address - Fax:888-651-5324
Practice Address - Street 1:33 UPPER RIVERDALE RD SW STE 118
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2642
Practice Address - Country:US
Practice Address - Phone:770-994-6969
Practice Address - Fax:888-651-5324
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030466207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA005739ZZDMedicaid
C72278Medicare UPIN
GA08BOPGRMedicare ID - Type Unspecified