Provider Demographics
NPI:1710969076
Name:LIEBELT, DONALD WALTER (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:WALTER
Last Name:LIEBELT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 SE 17TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-5586
Mailing Address - Country:US
Mailing Address - Phone:352-509-9165
Mailing Address - Fax:352-861-7725
Practice Address - Street 1:3515 SE 17TH ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471
Practice Address - Country:US
Practice Address - Phone:352-509-9165
Practice Address - Fax:352-861-7725
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56468207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10600OtherBCBS FL
FL10600OtherBCBS FL
E52996Medicare UPIN
FLDP943YMedicare PIN
FLDP943ZMedicare PIN