Provider Demographics
NPI:1699099242
Name:LIBBY, BRANDON (MD)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
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 1:2111 S 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-4711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 W CALIFORNIA BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3010
Practice Address - Country:US
Practice Address - Phone:626-397-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2024-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA259077207P00000X
MEMD20943207P00000X
CAC166621207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400156131Medicare PIN