Provider Demographics
NPI:1245220656
Name:LIEPKE, MATTHEW JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOHN
Last Name:LIEPKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 E SCHUYLER ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-1161
Mailing Address - Country:US
Mailing Address - Phone:315-343-6974
Mailing Address - Fax:315-342-3625
Practice Address - Street 1:33 E SCHUYLER ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-1161
Practice Address - Country:US
Practice Address - Phone:315-343-6974
Practice Address - Fax:315-342-3625
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234523207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02635330Medicaid
I26878Medicare UPIN
NY02635330Medicaid