Healthcare Provider Details

I. General information

NPI: 1467523365
Provider Name (Legal Business Name): JOHN G LIEB II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-4238
US

IV. Provider business mailing address

1600 SW ARCHER RD BOX 100214
GAINESVILLE FL
32610-0214
US

V. Phone/Fax

Practice location:
  • Phone: 352-392-2877
  • Fax: 352-392-3618
Mailing address:
  • Phone: 352-392-2877
  • Fax: 352-392-3618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD428599
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME101188
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: