MEDICARE: DR. TERRENCE PATRICK GLEASON M.D.

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	174400000X	Specialist	24347	AZ
2	174400000X	Specialist	MD00031165	WA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	340012308	OTHER	AZ	RAILROAD MEDICARE ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	AZ0395470	OTHER	AZ	BC/BS PROVIDER ID

General Provider Information

NPI Number	:	1740263953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRENCE PATRICK GLEASON M.D.

Provider Business Mailing Address
First Line	:	1972 MESQUITE AVE
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5729
Country	:	US
Telephone Number	:	928-855-8515
Fax Number	:	928-854-6206

Provider Business Practice Location Address
First Line	:	1810 MESQUITE AVE
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5886
Country	:	US
Telephone Number	:	928-855-8515
Fax Number	:	928-854-6206

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

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	03/30/2016

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Directions to “ DR. TERRENCE PATRICK GLEASON M.D.” Practice Location

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