Healthcare Provider Details

I. General information

NPI: 1750448973
Provider Name (Legal Business Name): HARRIS M LIEBERMAN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 CHESTNUT ST
PHILADELPHIA PA
19107-4213
US

IV. Provider business mailing address

3021 MIDVALE AVE
PHILADELPHIA PA
19129-1027
US

V. Phone/Fax

Practice location:
  • Phone: 215-922-0212
  • Fax:
Mailing address:
  • Phone: 215-438-2507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOET009024
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: