Healthcare Provider Details

I. General information

NPI: 1659335024
Provider Name (Legal Business Name): ZHANNA LIBIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

974 INMAN AVE SUITE 1-A
EDISON NJ
08820-1177
US

IV. Provider business mailing address

974 INMAN AVE SUITE 1-A
EDISON NJ
08820-1177
US

V. Phone/Fax

Practice location:
  • Phone: 908-412-8866
  • Fax: 908-412-9363
Mailing address:
  • Phone: 908-412-8866
  • Fax: 908-412-9363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA06945000
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier8061203
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: