Provider Demographics
NPI:1023039146
Name:LIEBMANN, OTTO (MD)
Entity Type:Individual
Prefix:
First Name:OTTO
Middle Name:
Last Name:LIEBMANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 WHIPPLE ST STE 3
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-3258
Mailing Address - Country:US
Mailing Address - Phone:401-519-0337
Mailing Address - Fax:
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:CLAVERICK 2
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-519-1604
Practice Address - Fax:401-272-0538
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD12526207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI12/13/2007OtherNHPRI
RI939025129OtherMEDICARE GROUP NUMBER
RI007059786OtherRI MEDICARE
MA1/27/2009OtherTUFTS HEALTH PLAN
RI2145464Medicaid
RI414642OtherBCBSRI
P00671205OtherRAILROAD MEDICARE
RI1023039146OtherNPI
MA2145464Medicaid