Provider Demographics
NPI:1639167943
Name:LIEBETREU, MARK ERNEST (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ERNEST
Last Name:LIEBETREU
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 BARKLEY CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-7530
Mailing Address - Country:US
Mailing Address - Phone:239-985-7171
Mailing Address - Fax:239-985-7118
Practice Address - Street 1:6091 S POINTE BLVD
Practice Address - Street 2:
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-4899
Practice Address - Country:US
Practice Address - Phone:239-985-7171
Practice Address - Fax:239-985-7118
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP0002191152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPG040OtherPTAN
FL620041900Medicaid
FL20537OtherBCBS
FL20537ZOtherPTAN