Provider Demographics
NPI:1275866907
Name:PUEBLO INFECTIOUS DISEASES, PLLC
Entity Type:Organization
Organization Name:PUEBLO INFECTIOUS DISEASES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LIEBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-369-7767
Mailing Address - Street 1:1505 GUMWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-7707
Mailing Address - Country:US
Mailing Address - Phone:719-369-7767
Mailing Address - Fax:
Practice Address - Street 1:ST. MARY CORWIN MEDICAL CENTER
Practice Address - Street 2:1008 MINNEQUA AVE
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004
Practice Address - Country:US
Practice Address - Phone:719-557-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-14
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty