Healthcare Provider Details

I. General information

NPI: 1295455772
Provider Name (Legal Business Name): GLEISY CALISEL ESCALANTE CARABALLO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GLEISY CALISEL CARABALLO SEGURA MD

II. Dates (important events)

Enumeration Date: 09/02/2022
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 PARK AVE
EAST ORANGE NJ
07017-1905
US

IV. Provider business mailing address

523 PARK AVENUE
CITY OF ORANGE NJ
07047-5901
US

V. Phone/Fax

Practice location:
  • Phone: 973-672-8573
  • Fax:
Mailing address:
  • Phone: 973-672-8573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA12630300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: