Healthcare Provider Details

I. General information

NPI: 1568405546
Provider Name (Legal Business Name): LIBBY FLEISCHER WILSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 W. ADAMS BLVD.
LOS ANGELES CA
90007-2664
US

IV. Provider business mailing address

403 W. ADAMS BLVD.
LOS ANGELES CA
90007-2664
US

V. Phone/Fax

Practice location:
  • Phone: 213-742-1433
  • Fax: 213-742-1496
Mailing address:
  • Phone: 213-742-1433
  • Fax: 213-742-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG18778
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberG18778
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberG18778
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: