Provider Demographics
NPI:1518077270
Name:LEIBMAN, MICHAEL ROY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROY
Last Name:LEIBMAN
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 1:106 GRAND AVE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-3574
Mailing Address - Country:US
Mailing Address - Phone:201-227-9000
Mailing Address - Fax:201-227-9900
Practice Address - Street 1:106 GRAND AVE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-3574
Practice Address - Country:US
Practice Address - Phone:201-227-9000
Practice Address - Fax:201-227-9900
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA60838174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8217863OtherGHI
NJ2K3198OtherHEALTHNET
NJ7640021OtherAETNA
NJ3139174OtherUSHC
NJP2040293OtherOXFORD
NJ3139174OtherUSHC
NJ031060Medicare ID - Type Unspecified