Provider Demographics
NPI:1053492900
Name:LIBERMAN, MICHAEL B (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:LIBERMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32987 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-0958
Mailing Address - Country:US
Mailing Address - Phone:248-549-9080
Mailing Address - Fax:248-549-4770
Practice Address - Street 1:32987 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-0958
Practice Address - Country:US
Practice Address - Phone:248-549-9080
Practice Address - Fax:248-549-4770
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002916152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4901002916OtherOD LICENSE
MI3318533Medicaid
MI3318533Medicaid
T96949Medicare UPIN