Provider Demographics
NPI:1417970872
Name:LEIB, MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:LEIB
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 1:622 W 168TH ST STE 464
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3720
Mailing Address - Country:US
Mailing Address - Phone:212-305-2303
Mailing Address - Fax:212-305-8449
Practice Address - Street 1:622 W 168TH ST STE 464
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-305-2303
Practice Address - Fax:212-305-8449
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124928-1207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00370356Medicaid
NY133367864OtherTAX ID
NY00370356Medicaid
NY11A771Medicare PIN