Healthcare Provider Details

I. General information

NPI: 1619009826
Provider Name (Legal Business Name): JEFFERY JOSEPH LIBRA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 EAGLE PARK DR NE STE 103
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

3355 EAGLE PARK DR NE STE 103
GRAND RAPIDS MI
49525-7004
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-7400
  • Fax: 616-942-7405
Mailing address:
  • Phone: 616-942-7400
  • Fax: 616-942-7405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301048963
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: