Provider Demographics
NPI:1558453779
Name:LIBERTELLA, JOHN (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LIBERTELLA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8419 BAY PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-3303
Mailing Address - Country:US
Mailing Address - Phone:718-331-0200
Mailing Address - Fax:718-331-0893
Practice Address - Street 1:9414 FLATLANDS AVE
Practice Address - Street 2:STE 201 E
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-3741
Practice Address - Country:US
Practice Address - Phone:718-649-6464
Practice Address - Fax:718-649-6426
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2023-10-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NYN005640213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02338998Medicaid
NY828611Medicare PIN
U81074Medicare UPIN