Provider Demographics
NPI:1619964996
Name:LEIBOV, ERNEST B (MD)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:B
Last Name:LEIBOV
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 1:350 SPARTA AVE
Mailing Address - Street 2:#A-5
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-1150
Mailing Address - Country:US
Mailing Address - Phone:973-729-0224
Mailing Address - Fax:973-729-0234
Practice Address - Street 1:350 SPARTA AVE
Practice Address - Street 2:#A-5
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-1150
Practice Address - Country:US
Practice Address - Phone:973-729-0224
Practice Address - Fax:973-729-0234
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM25 MA 43506002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ223115510OtherTAX ID
NJ223115510OtherTAX ID
NJ565988Medicare ID - Type Unspecified