Provider Demographics
NPI:1346224540
Name:LIBAO, RICHARD G (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:G
Last Name:LIBAO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:800-883-7243
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:15141 WHITTIER BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90603-2135
Practice Address - Country:US
Practice Address - Phone:562-945-2832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55784207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G557842Medicaid
CAWG55784AMedicare PIN
CAA93396Medicare UPIN
CACB237486Medicare PIN
CACB237485Medicare PIN
CAP01762596 (PAMA)Medicare PIN
CA050077928Medicare PIN
CA00G557842Medicaid
CABH173CMedicare PIN