Healthcare Provider Details

I. General information

NPI: 1619084803
Provider Name (Legal Business Name): JEFFREY DAVID LIBIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 EAST 78TH STREET
NEW YORK NY
10021-0302
US

IV. Provider business mailing address

102 EAST 78TH STREET
NEW YORK NY
10021-0302
US

V. Phone/Fax

Practice location:
  • Phone: 212-628-3800
  • Fax: 212-628-6606
Mailing address:
  • Phone: 212-628-3800
  • Fax: 212-628-6606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number146788
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: