Provider Demographics
NPI:1619294170
Name:OPTIMO PHYSICIAN ASSOCIATES
Entity Type:Organization
Organization Name:OPTIMO PHYSICIAN ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:LIBBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-744-4555
Mailing Address - Street 1:438 GANTTOWN RD
Mailing Address - Street 2:SUITE B-1
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2341
Mailing Address - Country:US
Mailing Address - Phone:609-744-4555
Mailing Address - Fax:856-258-4557
Practice Address - Street 1:438 GANTTOWN RD
Practice Address - Street 2:SUITE B-1
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2341
Practice Address - Country:US
Practice Address - Phone:609-744-4555
Practice Address - Fax:856-258-4557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05828000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty