Provider Demographics
NPI:1760541163
Name:LIBRA MEDICAL GROUP INC
Entity Type:Organization
Organization Name:LIBRA MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-650-4431
Mailing Address - Street 1:1410 MILLER DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90069-1422
Mailing Address - Country:US
Mailing Address - Phone:323-650-4431
Mailing Address - Fax:
Practice Address - Street 1:1410 MILLER DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90069-1422
Practice Address - Country:US
Practice Address - Phone:323-650-4431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50204207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW12278Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID