Provider Demographics
NPI:1184645723
Name:D&K LIEBOW LLC
Entity Type:Organization
Organization Name:D&K LIEBOW LLC
Other - Org Name:SOUTHERN VERMONT PODIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LIEBOW
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:802-254-0202
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01302-0910
Mailing Address - Country:US
Mailing Address - Phone:413-772-8500
Mailing Address - Fax:413-772-8900
Practice Address - Street 1:382 CANAL ST
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-6617
Practice Address - Country:US
Practice Address - Phone:802-254-0202
Practice Address - Fax:802-246-1300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213ES0103X
VT056-0000157332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1012948Medicaid
VT1012948Medicaid
VT5957700001Medicare NSC