Healthcare Provider Details

I. General information

NPI: 1063412328
Provider Name (Legal Business Name): JONATHAN LIEBLICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 STONELEIGH AVE PUTNAM HOSPITAL
CARMEL NY
10512-3997
US

IV. Provider business mailing address

43 KENSICO DR 2ND FLOOR
MOUNT KISCO NY
10549-1009
US

V. Phone/Fax

Practice location:
  • Phone: 845-279-5711
  • Fax:
Mailing address:
  • Phone: 914-666-8866
  • Fax: 914-666-6777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number213763
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: