Provider Demographics
NPI:1760463681
Name:LEIBOVITZ, JEFFRIE C (DPM)
Entity Type:Individual
Prefix:DR
First Name:JEFFRIE
Middle Name:C
Last Name:LEIBOVITZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9505 E 59TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46216-1025
Mailing Address - Country:US
Mailing Address - Phone:317-545-0505
Mailing Address - Fax:317-545-0506
Practice Address - Street 1:9505 E 59TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46216-1025
Practice Address - Country:US
Practice Address - Phone:317-545-0505
Practice Address - Fax:317-545-0506
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000550A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN480003471OtherMEDICARE RAILROAD #
IN35-1619801OtherTAX ID #
IN000000002077OtherMPLAN IDENTIFIER
IN00000313730OtherANTHEM BCBS ID #
IN1006619OtherTRICARE IDENTIFIER
IN000000002077OtherMPLAN IDENTIFIER
IN1006619OtherTRICARE IDENTIFIER
IN1272580001Medicare NSC