Healthcare Provider Details

I. General information

NPI: 1346230331
Provider Name (Legal Business Name): DANIEL L GLEASON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19260 SW 65TH AVE STE 340
TUALATIN OR
97062-5701
US

IV. Provider business mailing address

19260 SW 65TH AVE STE 340
TUALATIN OR
97062-5701
US

V. Phone/Fax

Practice location:
  • Phone: 503-691-9777
  • Fax: 503-692-6736
Mailing address:
  • Phone: 503-691-9777
  • Fax: 503-692-6736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD11923
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier260968
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: