Provider Demographics
NPI:1871585810
Name:GLEASON, PHILIP (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:GLEASON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4614 E SHEA BLVD
Mailing Address - Street 2:D-110
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3070
Mailing Address - Country:US
Mailing Address - Phone:480-404-3700
Mailing Address - Fax:
Practice Address - Street 1:4614 E SHEA BLVD
Practice Address - Street 2:D-110
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3070
Practice Address - Country:US
Practice Address - Phone:480-404-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30105208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ696065Medicaid
AZ696065Medicaid