Provider Demographics
NPI:1457356313
Name:GLEESON, TIMOTHY C (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:C
Last Name:GLEESON
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:PO BOX 1663
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-0031
Mailing Address - Country:US
Mailing Address - Phone:509-619-0562
Mailing Address - Fax:
Practice Address - Street 1:1804 W 51ST AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99337-4626
Practice Address - Country:US
Practice Address - Phone:509-619-0562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00018317207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1050194Medicaid
OR242529Medicaid
WAP001500722OtherRAILROAD MEDICARE
WAC92728Medicare UPIN
WAP001500722OtherRAILROAD MEDICARE