Provider Demographics
NPI:1124134002
Name:GIBILISCO, RAFFAELE A (MD, PA)
Entity type:Individual
Prefix:DR
First Name:RAFFAELE
Middle Name:A
Last Name:GIBILISCO
Suffix:
Gender:M
Credentials:MD, PA
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4067
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07059-0067
Mailing Address - Country:US
Mailing Address - Phone:201-295-1456
Mailing Address - Fax:201-295-0266
Practice Address - Street 1:435 59TH ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-2107
Practice Address - Country:US
Practice Address - Phone:201-295-1456
Practice Address - Fax:201-295-0266
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA060124207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6057608Medicaid
NJ6057608Medicaid
F75259Medicare UPIN