Basic Information
| Provider Information | |||||||||
| NPI: | 1346227428 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GABISAN | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 776 SHREWSBURY AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | TINTON FALLS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077243006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7325304949 | ||||||||
| FaxNumber: | 7325303618 | ||||||||
| Practice Location | |||||||||
| Address1: | 776 SHREWSBURY AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | TINTON FALLS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077243006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7325304949 | ||||||||
| FaxNumber: | 7325303618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 12/04/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MA069963 | NJ | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0004X | 25MA06996300 | NJ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7679694 | 01 | NJ | AETNA ID# | OTHER | 0047635 | 05 | NJ | MEDICAID | 3222403 | 05 | NJ | MEDICAID | P3362517 | 01 | NJ | OXFORD ID# | OTHER | CC3884 | 01 | NJ | RR MEDICARE GRP# | OTHER | P00163993 | 01 | NJ | RR MEDICARE | OTHER | J34051 | 01 | NJ | HEALTHNET ID# | OTHER |