Healthcare Provider Details

I. General information

NPI: 1376526434
Provider Name (Legal Business Name): WALTER DICKINSON LIEBKEMANN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 N ELM ST STE 200
GREENSBORO NC
27401-6304
US

IV. Provider business mailing address

PO BOX 85378
CHICAGO IL
60689-5378
US

V. Phone/Fax

Practice location:
  • Phone: 336-274-6682
  • Fax: 336-274-8097
Mailing address:
  • Phone: 336-274-6682
  • Fax: 336-274-8097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number9701459
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: