Healthcare Provider Details

I. General information

NPI: 1831132414
Provider Name (Legal Business Name): JEFFREY STEPHEN LIEBO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9980 SE SUNNYSIDE RD
CLACKAMAS OR
97015-9764
US

IV. Provider business mailing address

9800 SE SUNNYSIDE RD
CLACKAMAS OR
97015-9750
US

V. Phone/Fax

Practice location:
  • Phone: 503-813-0378
  • Fax:
Mailing address:
  • Phone: 503-813-0378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number16716
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: