Provider Demographics
NPI:1629007158
Name:LIEBENTHAL, JOHN S (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:S
Last Name:LIEBENTHAL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44871-0378
Mailing Address - Country:US
Mailing Address - Phone:419-609-1112
Mailing Address - Fax:419-609-1123
Practice Address - Street 1:2500 W STRUB RD
Practice Address - Street 2:SUITE 350
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-5390
Practice Address - Country:US
Practice Address - Phone:419-627-1471
Practice Address - Fax:419-627-8941
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-002433213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0678851Medicaid
OH480032146OtherMEDICARE RAILROAD
OHT80671Medicare UPIN
OH480032146OtherMEDICARE RAILROAD
OH0600675Medicare PIN