Basic Information
| Provider Information | |||||||||
| NPI: | 1528012853 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIBOON | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 POWELL ST STE 900 | ||||||||
| Address2: | |||||||||
| City: | EMERYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946081844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103502600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15615 POMERADO RD | ||||||||
| Address2: | |||||||||
| City: | POWAY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920642405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586134000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 04/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | MD00038681 | WA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | A65588 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8266652 | 05 | WA | MEDICAID |