Provider Demographics
NPI:1598756090
Name:LIEBERMAN PAN, JO (MD)
Entity Type:Individual
Prefix:DR
First Name:JO
Middle Name:
Last Name:LIEBERMAN PAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2742 DOW AVE
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-7242
Mailing Address - Country:US
Mailing Address - Phone:714-665-1600
Mailing Address - Fax:
Practice Address - Street 1:11420 WARNER AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-2529
Practice Address - Country:US
Practice Address - Phone:714-549-1300
Practice Address - Fax:714-433-3100
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77902207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A779020Medicaid
CAWA77902AMedicare PIN
CAEO387ZMedicare PIN
CA00A779020Medicaid