Provider Demographics
NPI:1114916533
Name:LIEBERMAN, BRYAN - (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:-
Last Name:LIEBERMAN
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 1:145 GAY ST
Mailing Address - Street 2:
Mailing Address - City:WESTWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02090-2596
Mailing Address - Country:US
Mailing Address - Phone:781-329-5642
Mailing Address - Fax:
Practice Address - Street 1:825 WASHINGTON ST
Practice Address - Street 2:SUITE 115
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-3441
Practice Address - Country:US
Practice Address - Phone:781-769-0465
Practice Address - Fax:781-769-4696
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA384912084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2061511Medicaid
MAK02087Medicaid
MA2061511Medicaid
MAB75207Medicare UPIN