Healthcare Provider Details

I. General information

NPI: 1760463681
Provider Name (Legal Business Name): JEFFRIE C LEIBOVITZ D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9505 E 59TH ST SUITE A
INDIANAPOLIS IN
46216-1025
US

IV. Provider business mailing address

9505 E 59TH ST SUITE A
INDIANAPOLIS IN
46216-1025
US

V. Phone/Fax

Practice location:
  • Phone: 317-545-0505
  • Fax: 317-545-0506
Mailing address:
  • Phone: 317-545-0505
  • Fax: 317-545-0506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07000550A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: