Healthcare Provider Details

I. General information

NPI: 1245220615
Provider Name (Legal Business Name): DAVID LIEBOW D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 05/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 CANAL ST
BRATTLEBORO VT
05301-6617
US

IV. Provider business mailing address

PO BOX 910
GREENFIELD MA
01302-0910
US

V. Phone/Fax

Practice location:
  • Phone: 802-254-0202
  • Fax: 802-246-1300
Mailing address:
  • Phone: 413-772-8500
  • Fax: 413-772-8900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0560000157
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: