Healthcare Provider Details

I. General information

NPI: 1265435713
Provider Name (Legal Business Name): HEDY LEIBOWITZ O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2005
Last Update Date: 11/19/2022
Certification Date: 11/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

359 BRICK BLVD
BRICK NJ
08723-6010
US

IV. Provider business mailing address

PO BOX 208944
DALLAS TX
75320-8944
US

V. Phone/Fax

Practice location:
  • Phone: 732-920-1330
  • Fax: 732-920-1370
Mailing address:
  • Phone: 636-200-4393
  • Fax: 636-527-0766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number270A00542500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: