Provider Demographics
NPI:1306817549
Name:LIEBERT, MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:LIEBERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 E MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2982
Mailing Address - Country:US
Mailing Address - Phone:631-265-8780
Mailing Address - Fax:
Practice Address - Street 1:260 E MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2982
Practice Address - Country:US
Practice Address - Phone:631-265-8780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211720-1207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02323339Medicaid
NY480B71Medicare ID - Type Unspecified
NY02323339Medicaid