Provider Demographics
NPI:1558327262
Name:LEIBSOHN, JOEL MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:MARTIN
Last Name:LEIBSOHN
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 1:19101 E VALLEY VIEW PKWY
Mailing Address - Street 2:SUITE D
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-6904
Mailing Address - Country:US
Mailing Address - Phone:816-836-8166
Mailing Address - Fax:816-836-3160
Practice Address - Street 1:19101 E VALLEY VIEW PKWY
Practice Address - Street 2:SUITE D
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-6904
Practice Address - Country:US
Practice Address - Phone:816-836-8166
Practice Address - Fax:816-836-3160
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7571207W00000X
KS0417025207W00000X
IA18621207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
06574019OtherBLUE CROSS BLUE SHIELD
MO1157990001Medicare NSC
06574019OtherBLUE CROSS BLUE SHIELD
KS0003641AMedicare ID - Type Unspecified
C50316Medicare UPIN