Healthcare Provider Details

I. General information

NPI: 1932109253
Provider Name (Legal Business Name): JEFFREY LIEBERMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3055 SOUTHWESTERN BLVD SUITE 104
ORCHARD PARK NY
14127-1231
US

IV. Provider business mailing address

51 S MEADOW DR
ORCHARD PARK NY
14127-2722
US

V. Phone/Fax

Practice location:
  • Phone: 716-677-6736
  • Fax: 716-677-6144
Mailing address:
  • Phone: 716-662-0293
  • Fax: 716-402-1862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number182918
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: