Healthcare Provider Details

I. General information

NPI: 1013919521
Provider Name (Legal Business Name): STEVEN LIEBERMAN OD, FAAO, PC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 06/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98120 QUEENS BLVD
REGO PARK NY
11374-4357
US

IV. Provider business mailing address

98120 QUEENS BLVD
REGO PARK NY
11374-4357
US

V. Phone/Fax

Practice location:
  • Phone: 718-896-4646
  • Fax: 718-897-1114
Mailing address:
  • Phone: 718-896-4646
  • Fax: 718-897-1114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV002959-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: