Provider Demographics
NPI:1083689335
Name:LEIBOWITZ, KEITH A (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:LEIBOWITZ
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 1:4120 DALE RD.
Mailing Address - Street 2:SUITE J8-240
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356
Mailing Address - Country:US
Mailing Address - Phone:209-522-6100
Mailing Address - Fax:209-522-6110
Practice Address - Street 1:700 17TH ST STE 102
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-1248
Practice Address - Country:US
Practice Address - Phone:209-522-6100
Practice Address - Fax:209-522-6110
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101239026207RG0100X
CAG129017207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA192063OtherANTHEM
P00313962OtherRR/MEDICARE
VA010251338Medicaid
VAE34012Medicare UPIN