Provider Demographics
NPI:1568415701
Name:LIEPMANN, PETER J (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:J
Last Name:LIEPMANN
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 1:257 S DE LACEY AVE UNIT 1130
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-4189
Mailing Address - Country:US
Mailing Address - Phone:518-302-6006
Mailing Address - Fax:
Practice Address - Street 1:2319 E WASHINGTON BLVD # 2
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-1945
Practice Address - Country:US
Practice Address - Phone:845-797-0950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC 89383207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00843150Medicaid
NY25D 961Medicare PIN
A61562Medicare UPIN