Healthcare Provider Details

I. General information

NPI: 1639104805
Provider Name (Legal Business Name): H. DAVID LIEBERMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 12/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277 NORTHERN BLVD SUITE 304
GREAT NECK NY
11021-4703
US

IV. Provider business mailing address

277 NORTHERN BLVD SUITE 304
GREAT NECK NY
11021-4703
US

V. Phone/Fax

Practice location:
  • Phone: 516-829-0105
  • Fax: 516-487-7240
Mailing address:
  • Phone: 516-829-0105
  • Fax: 516-487-7240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number125162
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: