Healthcare Provider Details

I. General information

NPI: 1285089029
Provider Name (Legal Business Name): LISA GLEASON, MD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2016
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

691 MORRO AVE
MORRO BAY CA
93442-2233
US

IV. Provider business mailing address

691 MORRO AVE
MORRO BAY CA
93442-2233
US

V. Phone/Fax

Practice location:
  • Phone: 805-225-5188
  • Fax: 844-971-7070
Mailing address:
  • Phone: 805-225-5188
  • Fax: 844-971-7070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA108043
License Number StateCA

VIII. Authorized Official

Name: LISA M GLEASON
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 805-225-5188