Provider Demographics
NPI:1346227428
Name:GABISAN, GLENN G (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:G
Last Name:GABISAN
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 1:776 SHREWSBURY AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-3006
Mailing Address - Country:US
Mailing Address - Phone:732-530-4949
Mailing Address - Fax:732-530-3618
Practice Address - Street 1:776 SHREWSBURY AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07724-3006
Practice Address - Country:US
Practice Address - Phone:732-530-4949
Practice Address - Fax:732-530-3618
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA069963207X00000X
NJ25MA06996300207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7679694OtherAETNA ID#
NJ0047635Medicaid
NJ3222403Medicaid
NJP3362517OtherOXFORD ID#
NJCC3884OtherRR MEDICARE GRP#
NJP00163993OtherRR MEDICARE
NJJ34051OtherHEALTHNET ID#
NJI16616Medicare UPIN
NJ3222403Medicaid
NJ0000405555Medicare ID - Type UnspecifiedMEDICARE GRP#