Provider Demographics
NPI:1093713190
Name:LIEB, JEREMY ISAAC (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:ISAAC
Last Name:LIEB
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 1:1450 TREAT BLVD # 300
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-2168
Mailing Address - Country:US
Mailing Address - Phone:925-952-2828
Mailing Address - Fax:
Practice Address - Street 1:2222 EAST ST
Practice Address - Street 2:STE 250
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2084
Practice Address - Country:US
Practice Address - Phone:925-689-6211
Practice Address - Fax:925-689-3857
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79348208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0067920Medicaid
CAGR0067920Medicaid
H76999Medicare UPIN
340020683Medicare ID - Type UnspecifiedRR