Healthcare Provider Details

I. General information

NPI: 1740592849
Provider Name (Legal Business Name): DANIEL JAMES LIEBERTZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2010
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5209 LAKE WASHINGTON BLVD NE STE 115
KIRKLAND WA
98033-7355
US

IV. Provider business mailing address

5209 LAKE WASHINGTON BLVD NE STE 115
KIRKLAND WA
98033-7355
US

V. Phone/Fax

Practice location:
  • Phone: 425-822-0300
  • Fax: 425-822-4999
Mailing address:
  • Phone: 425-822-0300
  • Fax: 425-822-4999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number073020
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number60671191
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: