Provider Demographics
NPI:1184642472
Name:LIBERTO, VINCENT (MD)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:
Last Name:LIBERTO
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 1:210 HIGHLAND PLACE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5909
Mailing Address - Country:US
Mailing Address - Phone:601-981-0235
Mailing Address - Fax:601-368-3875
Practice Address - Street 1:1500 E WOODROW WILSON AVE
Practice Address - Street 2:116A2
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5116
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:601-368-3875
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS070282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
B64112Medicare UPIN
MS10579Medicare ID - Type Unspecified