Provider Demographics
NPI:1629042627
Name:LIBKE, MATHEW J (MD)
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:J
Last Name:LIBKE
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:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:5255 E STOP 11 RD STE 450
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6342
Practice Address - Country:US
Practice Address - Phone:317-865-4800
Practice Address - Fax:317-865-4806
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056753A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200399890AMedicaid
IN020053837OtherRR MEDICARE
IN020053837OtherRR MEDICARE
F91594Medicare UPIN