Provider Demographics
NPI:1629237052
Name:MATTHEW A LIEBENTRITT, DO
Entity Type:Organization
Organization Name:MATTHEW A LIEBENTRITT, DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:A
Authorized Official - Last Name:LIEBENTRITT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:303-839-5105
Mailing Address - Street 1:5706 ASPEN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-3943
Mailing Address - Country:US
Mailing Address - Phone:303-829-5105
Mailing Address - Fax:303-927-7835
Practice Address - Street 1:5706 ASPEN CREEK DR
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-3943
Practice Address - Country:US
Practice Address - Phone:303-829-5105
Practice Address - Fax:303-927-7835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO95057021Medicaid
CO95057021Medicaid
COC808123Medicare PIN