1245220615 NPI number — DAVID LIEBOW D.P.M.

Table of content: DAVID LIEBOW D.P.M. (NPI 1245220615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245220615 NPI number — DAVID LIEBOW D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIEBOW
Provider First Name:
DAVID
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245220615
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 910
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01302-0910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-772-8500
Provider Business Mailing Address Fax Number:
413-772-8900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
382 CANAL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRATTLEBORO
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05301-6617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-254-0202
Provider Business Practice Location Address Fax Number:
802-246-1300
Provider Enumeration Date:
10/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  0560000157 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 19943 . This is a "BC/BS VT" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 30007741 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: OVN0942 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 78569 . This is a "MVP" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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