Provider Demographics
NPI:1619009826
Name:LIBRA, JEFFERY JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:JOSEPH
Last Name:LIBRA
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 1:3355 EAGLE PARK DR NE STE 103
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-7004
Mailing Address - Country:US
Mailing Address - Phone:616-942-7400
Mailing Address - Fax:616-942-7405
Practice Address - Street 1:3355 EAGLE PARK DR NE STE 103
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-942-7400
Practice Address - Fax:616-942-7405
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048963207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1619009826Medicaid
MI1235131137OtherBCBSM - BRONSON LAKEVIEW
MI2843350Medicaid
MIA79378Medicare UPIN
MI1619009826Medicaid