Healthcare Provider Details

I. General information

NPI: 1871534750
Provider Name (Legal Business Name): JOHN PAUL GLEASON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 01/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 CANAL ST STE 500
POOLER GA
31322-6007
US

IV. Provider business mailing address

143 CANAL ST STE 500
POOLER GA
31322-6007
US

V. Phone/Fax

Practice location:
  • Phone: 912-748-4527
  • Fax: 912-748-9016
Mailing address:
  • Phone: 912-748-4527
  • Fax: 912-748-9016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number065403
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: