Healthcare Provider Details

I. General information

NPI: 1669979316
Provider Name (Legal Business Name): PHILIP LIEBERMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 09/13/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 AREA MEDICAL CLINIC BLDG 22190
FPO AA
92058
US

IV. Provider business mailing address

PO BOX 555881
CAMP PENDLETON CA
92055-5881
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-2969
  • Fax:
Mailing address:
  • Phone: 760-725-2969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0101267819
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: