Provider Demographics
NPI:1639104698
Name:LIBAO, ELIZABETH MARIE FONTECHA (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH MARIE
Middle Name:FONTECHA
Last Name:LIBAO
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 1:1827 PISA CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-6321
Mailing Address - Country:US
Mailing Address - Phone:209-594-0180
Mailing Address - Fax:
Practice Address - Street 1:1524 MCHENRY AVE
Practice Address - Street 2:SUITE 315
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4500
Practice Address - Country:US
Practice Address - Phone:209-557-6200
Practice Address - Fax:209-557-6239
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-13767207Q00000X
AZ35781207Q00000X
CAA98064207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine