Healthcare Provider Details

I. General information

NPI: 1063495075
Provider Name (Legal Business Name): GARY J LIEBERMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 10/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N HIATUS RD SUITE 105
PEMBROKE PINES FL
33026-5214
US

IV. Provider business mailing address

900 S PINE ISLAND RD STE 800
PLANTATION FL
33324-3920
US

V. Phone/Fax

Practice location:
  • Phone: 954-431-8000
  • Fax: 954-436-0449
Mailing address:
  • Phone: 954-431-8000
  • Fax: 954-436-0449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME34672
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: