Provider Demographics
NPI:1124327093
Name:LIBBY, MATTHEW EDWIN (LDO)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:EDWIN
Last Name:LIBBY
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 W CHAPEL HILL ST
Mailing Address - Street 2:SUITE #3
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-3059
Mailing Address - Country:US
Mailing Address - Phone:919-302-1495
Mailing Address - Fax:
Practice Address - Street 1:1105 W CHAPEL HILL ST
Practice Address - Street 2:SUITE #3
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-3059
Practice Address - Country:US
Practice Address - Phone:919-302-1495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-17
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1960156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician