Healthcare Provider Details

I. General information

NPI: 1568415701
Provider Name (Legal Business Name): PETER J LIEPMANN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2319 E WASHINGTON BLVD # 2
PASADENA CA
91104-1945
US

IV. Provider business mailing address

257 S DE LACEY AVE UNIT 1130
PASADENA CA
91105-4189
US

V. Phone/Fax

Practice location:
  • Phone: 845-797-0950
  • Fax:
Mailing address:
  • Phone: 518-302-6006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberC 89383
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC 89383
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: