Provider Demographics
NPI:1922048016
Name:LIBBY, ERIC DAVID (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:DAVID
Last Name:LIBBY
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 1:955 MAIN ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-4302
Mailing Address - Country:US
Mailing Address - Phone:781-729-5855
Mailing Address - Fax:
Practice Address - Street 1:955 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:MA
Practice Address - Zip Code:01890-4302
Practice Address - Country:US
Practice Address - Phone:781-729-5855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA79352207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
303380OtherHARVARD PILGRIM HEALTH
MAJ30490OtherBLUE CROSS & BLUE SHIELD
MA509647OtherUS HEALTH
MA079352OtherTUFTS HEALTH
MA3126072Medicaid
MABX8226Medicare PIN
MAJ30490OtherBLUE CROSS & BLUE SHIELD