Provider Demographics
NPI:1659369122
Name:LIBSTER, BORIS (DO)
Entity Type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:LIBSTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 WHITE HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:HADDON HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:08035-1703
Mailing Address - Country:US
Mailing Address - Phone:856-547-1661
Mailing Address - Fax:856-547-6117
Practice Address - Street 1:217 WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:HADDON HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:08035-1703
Practice Address - Country:US
Practice Address - Phone:856-547-1661
Practice Address - Fax:856-547-6117
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2017-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB04369000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ109180803Medicaid
NJE13232Medicare UPIN
NJ190937C0SMedicare PIN
NJ110111585Medicare PIN