Provider Demographics
NPI:1164847141
Name:GIBLI, BENJAMIN (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:GIBLI
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 1:695 BUTTERNUT DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07417-2244
Mailing Address - Country:US
Mailing Address - Phone:201-891-5160
Mailing Address - Fax:
Practice Address - Street 1:100 W 57TH ST
Practice Address - Street 2:UNIT 8D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019
Practice Address - Country:US
Practice Address - Phone:201-310-8343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-27
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150946-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1164847141OtherNPI
NY150946-1OtherREGISTRATION CERTIFICATE, NYSED DIVISION OF PROFESSIONAL SERVICES - PHYSICIAN
NY9374509UPDOtherCERTIFICATE NUMBER: