Provider Demographics
NPI:1104097682
Name:DOUGLAS T GIBBENS MD LLC
Entity type:Organization
Organization Name:DOUGLAS T GIBBENS MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:T
Authorized Official - Last Name:GIBBENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-530-8989
Mailing Address - Street 1:766 SHREWSBURY AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-3001
Mailing Address - Country:US
Mailing Address - Phone:732-530-8989
Mailing Address - Fax:732-530-6365
Practice Address - Street 1:766 SHREWSBURY AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07724-3001
Practice Address - Country:US
Practice Address - Phone:732-530-8989
Practice Address - Fax:732-530-6365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA062255002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ085715Medicare PIN