Healthcare Provider Details

I. General information

NPI: 1710969076
Provider Name (Legal Business Name): DONALD WALTER LIEBELT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3515 SE 17TH ST
OCALA FL
34471
US

IV. Provider business mailing address

3515 SE 17TH ST
OCALA FL
34471-5586
US

V. Phone/Fax

Practice location:
  • Phone: 352-509-9165
  • Fax: 352-861-7725
Mailing address:
  • Phone: 352-509-9165
  • Fax: 352-861-7725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME56468
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: