Provider Demographics
NPI:1518948447
Name:LIVENGOOD, JOSEPH CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:CHARLES
Last Name:LIVENGOOD
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 1:759 HAIDA LN
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99712-2925
Mailing Address - Country:US
Mailing Address - Phone:907-370-2533
Mailing Address - Fax:
Practice Address - Street 1:1650 COWLES ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5907
Practice Address - Country:US
Practice Address - Phone:907-458-5358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37815208600000X
AKMEDS7502208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY116218700Medicaid
CO69307563Medicaid
TX1440711-01Medicaid
AK1584760Medicaid
COP00944662OtherMEDICARE RAILROAD CARRIER PTAN
NE84151469200Medicaid
TX1440711-01Medicaid
NE84151469200Medicaid
COCOA102141Medicare PIN