Healthcare Provider Details

I. General information

NPI: 1215960893
Provider Name (Legal Business Name): JEREMY M GLEESON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 09/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 GIBSON BLVD SE
ALBUQUERQUE NM
87108
US

IV. Provider business mailing address

PO BOX 27829
ALBUQUERQUE NM
87125
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-7455
  • Fax: 505-262-3485
Mailing address:
  • Phone: 505-232-1920
  • Fax: 505-727-9276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number89-203
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: