Provider Demographics
NPI:1225116445
Name:LIEBSON, SAMUEL (DPM)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:LIEBSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1597 DEER PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-8264
Mailing Address - Country:US
Mailing Address - Phone:360-452-6428
Mailing Address - Fax:360-457-9012
Practice Address - Street 1:1597 DEER PARK RD
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-8264
Practice Address - Country:US
Practice Address - Phone:360-452-6428
Practice Address - Fax:360-457-9012
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2280213ES0131X
MA1755213ES0131X
NYN3760213ES0131X
WA60015889213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8910070Medicare PIN
OHT80738Medicare UPIN
WA6699260001Medicare NSC