Provider Demographics
NPI:1548339849
Name:LIBENSON, BRADLEY NEAL (DO)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:NEAL
Last Name:LIBENSON
Suffix:
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:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:BERWICK
Mailing Address - State:ME
Mailing Address - Zip Code:03901
Mailing Address - Country:US
Mailing Address - Phone:207-698-7900
Mailing Address - Fax:207-698-7977
Practice Address - Street 1:6C SCHOOL ST
Practice Address - Street 2:
Practice Address - City:BERWICK
Practice Address - State:ME
Practice Address - Zip Code:03901
Practice Address - Country:US
Practice Address - Phone:207-698-7900
Practice Address - Fax:207-698-7977
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1276207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1078882OtherCIGNA
ME043568OtherANTHEM
ME174580000Medicaid
NH04YP12588NH01OtherANTHEM
NH30202194Medicaid
NH04YP12588NH01OtherANTHEM
ME174580000Medicaid