Provider Demographics
NPI:1619985462
Name:LIEBLICH, LAWRENCE MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:MARTIN
Last Name:LIEBLICH
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 1:39 OLD COACH RD
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3818
Mailing Address - Country:US
Mailing Address - Phone:631-821-4789
Mailing Address - Fax:631-689-6821
Practice Address - Street 1:9 BROOKSITE DR
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3400
Practice Address - Country:US
Practice Address - Phone:631-390-7800
Practice Address - Fax:631-390-7821
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY135570207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY68A30OtherEMPIRE BCBS
NY00770021Medicaid
NY11-2644403OtherEMPIRE PLAN
NY218790POtherHIP
NYAJ48951OtherMDNY
NY218791POtherHIP
NYAJ48951OtherMDNY
NY218790POtherHIP