Healthcare Provider Details

I. General information

NPI: 1316980568
Provider Name (Legal Business Name): JAY ALAN LIEBERMAN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 12/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2964 N STATE ROAD 7 SUITE 205
MARGATE FL
33063-5715
US

IV. Provider business mailing address

2964 N STATE ROAD 7 SUITE 205
MARGATE FL
33063-5715
US

V. Phone/Fax

Practice location:
  • Phone: 954-580-4080
  • Fax: 954-580-4081
Mailing address:
  • Phone: 954-580-4080
  • Fax: 954-580-4081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO0001449
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO0001449
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO0001449
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: