Provider Demographics
NPI:1508864919
Name:LEIBOWITZ, MARK IRA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:IRA
Last Name:LEIBOWITZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4527 N SWAN ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-4720
Mailing Address - Country:US
Mailing Address - Phone:505-534-4757
Mailing Address - Fax:
Practice Address - Street 1:1264 E 32ND ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-7229
Practice Address - Country:US
Practice Address - Phone:505-534-1444
Practice Address - Fax:505-534-1449
Is Sole Proprietor?:No
Enumeration Date:2005-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2003-0544208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMD56764Medicare UPIN