Provider Demographics
NPI:1114996428
Name:LIBSCH, KAREN D (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:D
Last Name:LIBSCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:ST MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-1813
Mailing Address - Country:US
Mailing Address - Phone:208-245-2591
Mailing Address - Fax:208-245-5246
Practice Address - Street 1:229 S 8TH ST
Practice Address - Street 2:
Practice Address - City:ST MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-1813
Practice Address - Country:US
Practice Address - Phone:208-245-2591
Practice Address - Fax:208-245-5246
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41146207Q00000X
IDM-10876207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1114996428OtherPREMERA BLUE CROSS
CO40984524Medicaid
ID808521300Medicaid
ID78176OtherBLUE CROSS OF IDAHO
ID808521300Medicaid
CO40984524Medicaid