Provider Demographics
NPI:1225484694
Name:LIEBERMAN, EVAN
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:LIEBERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 E 84TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-2050
Mailing Address - Country:US
Mailing Address - Phone:917-751-1835
Mailing Address - Fax:
Practice Address - Street 1:660 1ST AVE
Practice Address - Street 2:FL 3
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016
Practice Address - Country:US
Practice Address - Phone:212-263-5219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY3166572085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program