MEDICARE: DR. LISA ANNE GLEASON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	35560	NC
2	207RC0000X	Cardiovascular Disease Physician	A65766	CA
3	207RC0001X	Clinical Cardiac Electrophysiology Physician	A65766	CA

General Provider Information

NPI Number	:	1700865045
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA ANNE GLEASON MD

Provider Business Mailing Address
First Line	:	2600 VIA DE LA VALLE
Second Line	:	SUITE 200
City	:	DEL MAR
State	:	CA
Zip	:	92014-1992
Country	:	US
Telephone Number	:	858-939-6561
Fax Number	:	858-874-2379

Provider Business Practice Location Address
First Line	:	2600 VIA DE LA VALLE
Second Line	:	SUITE 200
City	:	DEL MAR
State	:	CA
Zip	:	92014-1992
Country	:	US
Telephone Number	:	858-939-6561
Fax Number	:	858-874-2379

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2006
Last Update Date	:	06/01/2015

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