Provider Demographics
NPI:1588656995
Name:LIBIRAN, MATTHEW A R (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:A R
Last Name:LIBIRAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 WEST CHICAGO AVENUE
Mailing Address - Street 2:SUITE F
Mailing Address - City:EAST CHICAGO
Mailing Address - State:IN
Mailing Address - Zip Code:46312-3260
Mailing Address - Country:US
Mailing Address - Phone:219-397-0193
Mailing Address - Fax:219-397-0657
Practice Address - Street 1:100 WEST CHICAGO AVENUE
Practice Address - Street 2:SUITE F
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-3260
Practice Address - Country:US
Practice Address - Phone:219-397-0193
Practice Address - Fax:219-397-0657
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059738A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
01059738AOtherMEDICAL LICENSE
IN200531170Medicaid
INL39758Medicare UPIN
IN142670PMedicare PIN
01059738AOtherMEDICAL LICENSE