Provider Demographics
NPI:1275723520
Name:FRED A LIEBOWITZ MD PA
Entity Type:Organization
Organization Name:FRED A LIEBOWITZ MD PA
Other - Org Name:HEADACHE & PAIN MANAGEMENT OF SWFL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:LIEBOWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-278-1000
Mailing Address - Street 1:6150 DIAMOND CENTRE CT
Mailing Address - Street 2:700-1
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4365
Mailing Address - Country:US
Mailing Address - Phone:239-278-1000
Mailing Address - Fax:239-278-0501
Practice Address - Street 1:6150 DIAMOND CENTRE CT
Practice Address - Street 2:700-1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4365
Practice Address - Country:US
Practice Address - Phone:239-278-1000
Practice Address - Fax:239-278-0501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME60344208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME60344Medicare UPIN