1861574279 NPI number — JOSEPH ANTHONY LIBBY MD, FACP, CMD

Table of content: JOSEPH ANTHONY LIBBY MD, FACP, CMD (NPI 1861574279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861574279 NPI number — JOSEPH ANTHONY LIBBY MD, FACP, CMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIBBY
Provider First Name:
JOSEPH
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD, FACP, CMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861574279
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2954 MALLORY CIR STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KISSIMMEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34747-1822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
689-207-0654
Provider Business Mailing Address Fax Number:
407-396-1028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2954 MALLORY CIR STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KISSIMMEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34747-1822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
689-207-0654
Provider Business Practice Location Address Fax Number:
407-396-1028
Provider Enumeration Date:
10/19/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MA58280 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: ME148336 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)