Healthcare Provider Details

I. General information

NPI: 1164957098
Provider Name (Legal Business Name): AUGUSTUS GLEASON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2017
Last Update Date: 02/08/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MERCY CIRCLE DEPARTMENT OF SURGERY
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

PO BOX 555191
CAMP PENDLETON CA
92055-5191
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-1356
  • Fax:
Mailing address:
  • Phone: 760-725-1356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number191356
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number208600000X
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: