Provider Demographics
NPI:1235172636
Name:LIEBAU, MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:LIEBAU
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 OLD 63 S
Mailing Address - Street 2:STE B
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8404
Mailing Address - Country:US
Mailing Address - Phone:573-442-2020
Mailing Address - Fax:573-442-4502
Practice Address - Street 1:1306 OLD 63 S
Practice Address - Street 2:STE B
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8404
Practice Address - Country:US
Practice Address - Phone:573-442-2020
Practice Address - Fax:573-442-4502
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02445152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT44074Medicare UPIN