Healthcare Provider Details

I. General information

NPI: 1619990116
Provider Name (Legal Business Name): MICHAEL JONATHAN LIEBER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 01/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SANTA MONICA BLVD STE 1190W
SANTA MONICA CA
90404-2102
US

IV. Provider business mailing address

2001 SANTA MONICA BLVD STE 1190W
SANTA MONICA CA
90404-2102
US

V. Phone/Fax

Practice location:
  • Phone: 310-453-1414
  • Fax: 310-362-8775
Mailing address:
  • Phone: 310-453-1414
  • Fax: 310-362-8775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberG32244
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberG32244
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License NumberG32244
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: