Provider Demographics
NPI:1710242086
Name:GIBREAL, MOHAMMED (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:
Last Name:GIBREAL
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 1:2200 FLETCHER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-5005
Mailing Address - Country:US
Mailing Address - Phone:201-461-6200
Mailing Address - Fax:201-461-7204
Practice Address - Street 1:2200 FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-5005
Practice Address - Country:US
Practice Address - Phone:201-461-6200
Practice Address - Fax:201-461-7204
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10334000207RC0000X
IL036155698207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0625329Medicaid