Provider Demographics
NPI:1417004664
Name:LIBERATORE, JAN
Entity Type:Individual
Prefix:MR
First Name:JAN
Middle Name:
Last Name:LIBERATORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2751 WESTINGHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-8100
Mailing Address - Country:US
Mailing Address - Phone:607-739-0325
Mailing Address - Fax:
Practice Address - Street 1:2751 WESTINGHOUSE RD
Practice Address - Street 2:
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-8100
Practice Address - Country:US
Practice Address - Phone:607-739-0325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC004009-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
0643720001Medicare ID - Type Unspecified