Healthcare Provider Details

I. General information

NPI: 1710140462
Provider Name (Legal Business Name): GWEN ELLEN GLEASON-ROHRER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4290 POLK AVE
SAN DIEGO CA
92105-1524
US

IV. Provider business mailing address

4290 POLK AVE
SAN DIEGO CA
92105-1524
US

V. Phone/Fax

Practice location:
  • Phone: 619-563-0250
  • Fax:
Mailing address:
  • Phone: 619-563-0250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA112176
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: