=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619985462
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAWRENCE MARTIN LIEBLICH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2006
-----------------------------------------------------
Last Update Date | 12/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 BROOKSITE DR
-----------------------------------------------------
City | SMITHTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11787-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-390-7800
-----------------------------------------------------
Fax | 631-390-7821
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39 OLD COACH RD
-----------------------------------------------------
City | EAST SETAUKET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11733-3818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-821-4789
-----------------------------------------------------
Fax | 631-689-6821
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 135570
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------