Provider Demographics
NPI:1740263953
Name:GLEASON, TERRENCE PATRICK (MD)
Entity type:Individual
Prefix:DR
First Name:TERRENCE
Middle Name:PATRICK
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 1:1972 MESQUITE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5729
Mailing Address - Country:US
Mailing Address - Phone:928-855-8515
Mailing Address - Fax:928-854-6206
Practice Address - Street 1:1810 MESQUITE AVE
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5886
Practice Address - Country:US
Practice Address - Phone:928-855-8515
Practice Address - Fax:928-854-6206
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24347174400000X
WAMD00031165174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ351271Medicaid
AZ340012308OtherRAILROAD MEDICARE ID
AZAZ0395470OtherBC/BS PROVIDER ID
AZG32840Medicare UPIN
AZ340012308OtherRAILROAD MEDICARE ID