Provider Demographics
NPI:1720227010
Name:GLEASON, KATHERINE MICHELE BAUGHMAN (OD, FAAO)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MICHELE BAUGHMAN
Last Name:GLEASON
Suffix:
Gender:F
Credentials:OD, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 LINCOLN WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2540
Mailing Address - Country:US
Mailing Address - Phone:208-770-3814
Mailing Address - Fax:208-691-6327
Practice Address - Street 1:8378 N GOVERNMENT WAY
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9258
Practice Address - Country:US
Practice Address - Phone:208-209-7100
Practice Address - Fax:208-209-7911
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID100170152W00000X
IDODP-100170152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808375601Medicaid
ID808375600Medicaid