MEDICARE: JEFFREY STEPHEN LIEBO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	16716	OR

General Provider Information

NPI Number	:	1831132414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY STEPHEN LIEBO M.D.

Provider Business Mailing Address
First Line	:	9800 SE SUNNYSIDE RD
Second Line	:
City	:	CLACKAMAS
State	:	OR
Zip	:	97015-9750
Country	:	US
Telephone Number	:	503-813-0378
Fax Number	:

Provider Business Practice Location Address
First Line	:	9980 SE SUNNYSIDE RD
Second Line	:
City	:	CLACKAMAS
State	:	OR
Zip	:	97015-9764
Country	:	US
Telephone Number	:	503-813-0378
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	07/11/2007

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