Healthcare Provider Details

I. General information

NPI: 1346227428
Provider Name (Legal Business Name): GLENN G GABISAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 12/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

776 SHREWSBURY AVE SUITE 201
TINTON FALLS NJ
07724-3006
US

IV. Provider business mailing address

776 SHREWSBURY AVE SUITE 201
TINTON FALLS NJ
07724-3006
US

V. Phone/Fax

Practice location:
  • Phone: 732-530-4949
  • Fax: 732-530-3618
Mailing address:
  • Phone: 732-530-4949
  • Fax: 732-530-3618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMA069963
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number25MA06996300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: