Healthcare Provider Details

I. General information

NPI: 1093702458
Provider Name (Legal Business Name): MARLA JEAN GLEASON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 MEDICAL CENTER DR
BAY MINETTE AL
36507-4163
US

IV. Provider business mailing address

2001 MEDICAL CENTER DR
BAY MINETTE AL
36507-4163
US

V. Phone/Fax

Practice location:
  • Phone: 251-937-7016
  • Fax: 251-937-7612
Mailing address:
  • Phone: 251-937-7016
  • Fax: 251-937-7612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number11955
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: