Provider Demographics
NPI:1780749820
Name:GLEASON, JONATHAN LEE (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:LEE
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:101 HALTON VILLAGE CIR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-6825
Practice Address - Country:US
Practice Address - Phone:864-455-1600
Practice Address - Fax:864-286-5298
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT186681207V00000X
VA0101251665207VF0040X, 207VG0400X
AL29368207VG0400X
SC88740207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51599090OtherBLUE CROSS
MS02536526Medicaid
AL113533Medicaid
SC557400Medicaid
AL51599089OtherBLUE CROSS
AL113528Medicaid
AL113530Medicaid
AL51599092OtherBLUE CROSS