Healthcare Provider Details

I. General information

NPI: 1205613783
Provider Name (Legal Business Name): TIMOTHY JOSEPH LIEBERENZ OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 09/11/2023
Certification Date: 09/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8495 CRATER LAKE HWY
WHITE CITY OR
97503-3011
US

IV. Provider business mailing address

PO BOX 1082
MERLIN OR
97532-1082
US

V. Phone/Fax

Practice location:
  • Phone: 541-826-2111
  • Fax:
Mailing address:
  • Phone: 541-279-4792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberATI4707
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: