Provider Demographics
NPI:1689653362
Name:LIEBERGALL, GORDON SIDNEY (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:SIDNEY
Last Name:LIEBERGALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:222 ROUTE 59
Mailing Address - Street 2:SUITE 207
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-5204
Mailing Address - Country:US
Mailing Address - Phone:845-357-2500
Mailing Address - Fax:845-368-3937
Practice Address - Street 1:222 ROUTE 59
Practice Address - Street 2:SUITE 207
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-5204
Practice Address - Country:US
Practice Address - Phone:845-357-2500
Practice Address - Fax:845-368-3937
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY084611207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00127838Medicaid
NM084611OtherSTATE MEDICAL LICENSE NUM
NM084611OtherSTATE MEDICAL LICENSE NUM
NY17789ADD1Medicare ID - Type Unspecified