Provider Demographics
NPI:1215960893
Name:GLEESON, JEREMY M (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:M
Last Name:GLEESON
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 27829
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125
Mailing Address - Country:US
Mailing Address - Phone:505-232-1920
Mailing Address - Fax:505-727-9276
Practice Address - Street 1:5400 GIBSON BLVD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108
Practice Address - Country:US
Practice Address - Phone:505-262-7455
Practice Address - Fax:505-262-3485
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM89-203207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM20776Medicaid
D20376Medicare UPIN