Provider Demographics
NPI:1316023526
Name:LEIBOLD, WALTER CLIFFORD (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:CLIFFORD
Last Name:LEIBOLD
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 1:2106 S GRAY RD
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-9606
Mailing Address - Country:US
Mailing Address - Phone:989-345-7880
Mailing Address - Fax:989-345-7882
Practice Address - Street 1:2106 S GRAY RD
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-9606
Practice Address - Country:US
Practice Address - Phone:989-345-7880
Practice Address - Fax:989-345-7882
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIWL041417208600000X
MI4301041417208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2125588Medicaid
0650005Medicare ID - Type Unspecified
MI2125588Medicaid