Healthcare Provider Details

I. General information

NPI: 1447712740
Provider Name (Legal Business Name): DAVID LIEPA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 09/20/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 S 23RD ST
FORT PIERCE FL
34950-4803
US

IV. Provider business mailing address

5380 TECH DATA DR STE 202
CLEARWATER FL
33760-3122
US

V. Phone/Fax

Practice location:
  • Phone: 772-461-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME155902
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: