Provider Demographics
NPI:1346214533
Name:OXENBERG, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:OXENBERG
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 1:525 TILTON RD
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08225-1217
Mailing Address - Country:US
Mailing Address - Phone:609-272-0655
Mailing Address - Fax:
Practice Address - Street 1:53 W WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9450
Practice Address - Country:US
Practice Address - Phone:609-272-0655
Practice Address - Fax:609-272-9188
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039259L207Q00000X
NJ25MA10211100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001489863007Medicaid
B41992Medicare UPIN
PA001489863007Medicaid