Provider Demographics
NPI:1629569744
Name:LIBERTY PEDIATRICS, LLC
Entity Type:Organization
Organization Name:LIBERTY PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CAMERON
Authorized Official - Middle Name:C
Authorized Official - Last Name:DESHAZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-492-0126
Mailing Address - Street 1:4387 BOULDER LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35242-2116
Mailing Address - Country:US
Mailing Address - Phone:205-492-0126
Mailing Address - Fax:
Practice Address - Street 1:3735 CORPORATE WOODS DR STE 105
Practice Address - Street 2:
Practice Address - City:VESTAVIA
Practice Address - State:AL
Practice Address - Zip Code:35242-2296
Practice Address - Country:US
Practice Address - Phone:205-492-0126
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty