Provider Demographics
NPI:1275862450
Name:GLEASON, DESIREE SUE (DO)
Entity type:Individual
Prefix:DR
First Name:DESIREE
Middle Name:SUE
Last Name:GLEASON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 MAINE STREET
Mailing Address - Street 2:MSO LIBRARY
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044
Mailing Address - Country:US
Mailing Address - Phone:785-505-2988
Mailing Address - Fax:
Practice Address - Street 1:4525 W 6TH ST STE 100
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-7700
Practice Address - Country:US
Practice Address - Phone:785-505-5160
Practice Address - Fax:785-505-5282
Is Sole Proprietor?:No
Enumeration Date:2009-12-16
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO51023207R00000X
COTL3359207R00000X
KS05-49159207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO022562OtherKAISER COMMERCIAL NUMBER
CO87880318Medicaid
KS30005157700001Medicaid