Provider Demographics
NPI:1356379572
Name:LIBEN, NICHOLAS JOHN JR (DO)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JOHN
Last Name:LIBEN
Suffix:JR
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 1:2114 ST RT 113 E
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:OH
Mailing Address - Zip Code:44846-9483
Mailing Address - Country:US
Mailing Address - Phone:419-499-4500
Mailing Address - Fax:419-499-1219
Practice Address - Street 1:272 BENEDICT AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:OH
Practice Address - Zip Code:44857-2374
Practice Address - Country:US
Practice Address - Phone:419-668-8101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005352207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000154485OtherBC & BS
OH0892100Medicaid
OHF40257Medicare UPIN
OHLI0725954Medicare ID - Type Unspecified