Healthcare Provider Details

I. General information

NPI: 1326077181
Provider Name (Legal Business Name): MARY LU GLEESON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 SOUTH AVE SUITE 207
ROCHESTER NY
14620
US

IV. Provider business mailing address

1000 SOUTH AVE BOX 58
ROCHESTER NY
14620
US

V. Phone/Fax

Practice location:
  • Phone: 585-341-0209
  • Fax: 585-341-8096
Mailing address:
  • Phone: 585-341-0209
  • Fax: 585-341-8096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number177602
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: