Provider Demographics
NPI:1053488007
Name:LIEBENTRITT, MATTHEW AARON (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:AARON
Last Name:LIEBENTRITT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12169 SHERIDAN BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-2459
Mailing Address - Country:US
Mailing Address - Phone:303-603-9400
Mailing Address - Fax:303-603-9420
Practice Address - Street 1:12169 SHERIDAN BLVD
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-2459
Practice Address - Country:US
Practice Address - Phone:303-603-9400
Practice Address - Fax:303-603-9420
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41855207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO82778868Medicaid
P00462907OtherMEDICARE RAILROAD
COH87972Medicare UPIN
COC808123Medicare PIN
CO82778868Medicaid