Provider Demographics
NPI:1568405546
Name:WILSON, LIBBY FLEISCHER (MD)
Entity Type:Individual
Prefix:
First Name:LIBBY
Middle Name:FLEISCHER
Last Name:WILSON
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 1:403 W. ADAMS BLVD.
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-2664
Mailing Address - Country:US
Mailing Address - Phone:213-742-1433
Mailing Address - Fax:213-742-1496
Practice Address - Street 1:403 W. ADAMS BLVD.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-2664
Practice Address - Country:US
Practice Address - Phone:213-742-1433
Practice Address - Fax:213-742-1496
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG18778174400000X, 208200000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No174400000XOther Service ProvidersSpecialist
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G187780Medicare UPIN
CAG18778Medicare ID - Type Unspecified