Provider Demographics
NPI:1376603241
Name:LEIBOVITZ, ROSS M (MD)
Entity Type:Individual
Prefix:DR
First Name:ROSS
Middle Name:M
Last Name:LEIBOVITZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 HEALTH PARK DR STE 370
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-9586
Mailing Address - Country:US
Mailing Address - Phone:303-666-9839
Mailing Address - Fax:303-666-1949
Practice Address - Street 1:90 HEALTH PARK DR STE 370
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-9586
Practice Address - Country:US
Practice Address - Phone:303-666-9839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25793208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01257930Medicaid
COC5409-1Medicare ID - Type Unspecified
CO01257930Medicaid