1275862450 NPI number — DR. DESIREE SUE GLEASON D.O.

Table of content: DR. DESIREE SUE GLEASON D.O. (NPI 1275862450)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275862450 NPI number — DR. DESIREE SUE GLEASON D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLEASON
Provider First Name:
DESIREE
Provider Middle Name:
SUE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275862450
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
325 MAINE STREET
Provider Second Line Business Mailing Address:
MSO LIBRARY
Provider Business Mailing Address City Name:
LAWRENCE
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-505-2988
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4525 W 6TH ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWRENCE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66049-7700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-505-5160
Provider Business Practice Location Address Fax Number:
785-505-5282
Provider Enumeration Date:
12/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  51023 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: TL3359 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 05-49159 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 022562 . This is a "KAISER COMMERCIAL NUMBER" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 87880318 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30005157700001 , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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