Healthcare Provider Details

I. General information

NPI: 1598119919
Provider Name (Legal Business Name): DOUGLAS F LIEB MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1053 MEDICAL CENTER DR STE 242
ORANGE CITY FL
32763-8261
US

IV. Provider business mailing address

1053 MEDICAL CENTER DR STE 242
ORANGE CITY FL
32763-8261
US

V. Phone/Fax

Practice location:
  • Phone: 386-456-0210
  • Fax: 386-456-0219
Mailing address:
  • Phone: 386-456-0210
  • Fax: 386-456-0219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME82424
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME82424
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberME82424
License Number StateFL

VIII. Authorized Official

Name: DOUGLAS F LIEB
Title or Position: PRESIDENT
Credential: M.D.
Phone: 407-739-2598