Provider Demographics
NPI:1508979741
Name:LIEBERMAN, DANIEL A (OD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:A
Last Name:LIEBERMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4418 W DIVERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-1924
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4418 W DIVERSEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1924
Practice Address - Country:US
Practice Address - Phone:773-736-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008138152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7235044OtherAETNA
1636706OtherBCBS
K15488OtherMEDICARE
IL046008138Medicaid
210209OtherGROUP MEDICARE
211019OtherGROUP MEDICARE
410014597OtherRR MEDICARE
K44386OtherMEDICARE
7235044OtherAETNA
ILU63076Medicare UPIN