Provider Demographics
NPI:1386673994
Name:LIEB, DOUGLAS FREDERICK (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:FREDERICK
Last Name:LIEB
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 1:1053 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 251
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8260
Mailing Address - Country:US
Mailing Address - Phone:386-456-0210
Mailing Address - Fax:386-456-0219
Practice Address - Street 1:1053 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 251
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8260
Practice Address - Country:US
Practice Address - Phone:386-456-0210
Practice Address - Fax:386-456-0219
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82424207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261933400Medicaid
FL261933400Medicaid
FLH46155Medicare UPIN