Provider Demographics
NPI:1245220615
Name:LIEBOW, DAVID (DPM)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:LIEBOW
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: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
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0560000157213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT19943OtherBC/BS VT
NH30007741Medicaid
VTOVN0942Medicaid
VT78569OtherMVP
VN0942Medicare ID - Type Unspecified
VTOVN0942Medicaid