Provider Demographics
NPI:1598119919
Name:DOUGLAS F LIEB MD LLC
Entity Type:Organization
Organization Name:DOUGLAS F LIEB MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:F
Authorized Official - Last Name:LIEB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-739-2598
Mailing Address - Street 1:1053 MEDICAL CENTER DR STE 242
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8261
Mailing Address - Country:US
Mailing Address - Phone:386-456-0210
Mailing Address - Fax:386-456-0219
Practice Address - Street 1:1053 MEDICAL CENTER DR STE 242
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8261
Practice Address - Country:US
Practice Address - Phone:386-456-0210
Practice Address - Fax:386-456-0219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-21
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82424207W00000X, 208600000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261933400Medicaid
FLH46155Medicare UPIN
FL02455YOtherMEDICARE ID - TYPE UNSPECIFIED