Healthcare Provider Details

I. General information

NPI: 1871297622
Provider Name (Legal Business Name): BLAKE LIEBERMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8201 W BROWARD BLVD
PLANTATION FL
33324-2701
US

IV. Provider business mailing address

8201 W BROWARD BLVD
PLANTATION FL
33324-2701
US

V. Phone/Fax

Practice location:
  • Phone: 954-473-6600
  • Fax:
Mailing address:
  • Phone: 954-473-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36.004228
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: