Healthcare Provider Details

I. General information

NPI: 1245345008
Provider Name (Legal Business Name): IVAN M LIEBERBURG PH.D., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 08/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 STEVENS AVE SUITE 100
SOLANA BEACH CA
92075-2057
US

IV. Provider business mailing address

440 STEVENS AVE 100
SOLANA BEACH CA
92075-2057
US

V. Phone/Fax

Practice location:
  • Phone: 650-302-8344
  • Fax: 858-400-3101
Mailing address:
  • Phone: 650-302-8344
  • Fax: 858-400-3101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberG45771
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: