Provider Demographics
NPI:1821066283
Name:GILSENAN, MICHELE THERESA (DO)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:THERESA
Last Name:GILSENAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1640
Mailing Address - Country:US
Mailing Address - Phone:732-388-7300
Mailing Address - Fax:732-388-1330
Practice Address - Street 1:67 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1640
Practice Address - Country:US
Practice Address - Phone:732-388-7300
Practice Address - Fax:732-388-1330
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB53933207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF12985Medicare UPIN
NJ705406Medicare ID - Type Unspecified