Provider Demographics
NPI:1306012182
Name:KIBREA, S M GOLAM (MD)
Entity Type:Individual
Prefix:
First Name:S M
Middle Name:GOLAM
Last Name:KIBREA
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 1:1809 JOHN F. KENNEDY BLVD,
Mailing Address - Street 2:GROUND FLOOR
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305
Mailing Address - Country:US
Mailing Address - Phone:201-763-6664
Mailing Address - Fax:201-621-5820
Practice Address - Street 1:170 PROSPECT AVE,
Practice Address - Street 2:SUITE 6
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07801
Practice Address - Country:US
Practice Address - Phone:201-763-6664
Practice Address - Fax:201-621-5820
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08794300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
238465Medicare PIN
NJI51007Medicare UPIN