Provider Demographics
NPI:1639224728
Name:GRIBBON, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GRIBBON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 43019
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-0019
Mailing Address - Country:US
Mailing Address - Phone:973-744-3382
Mailing Address - Fax:973-509-3205
Practice Address - Street 1:62 S FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2629
Practice Address - Country:US
Practice Address - Phone:973-744-3382
Practice Address - Fax:973-509-3205
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03676800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD07058Medicare UPIN