Provider Demographics
NPI:1851301139
Name:THEODORE W LIEBERMAN MD PC
Entity Type:Organization
Organization Name:THEODORE W LIEBERMAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:W
Authorized Official - Last Name:LIEBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-722-5477
Mailing Address - Street 1:70 E 96TH ST
Mailing Address - Street 2:1B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-0747
Mailing Address - Country:US
Mailing Address - Phone:212-722-5477
Mailing Address - Fax:212-722-5599
Practice Address - Street 1:70 E 96TH ST
Practice Address - Street 2:1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-0747
Practice Address - Country:US
Practice Address - Phone:212-722-5477
Practice Address - Fax:212-722-5599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY083922207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NS3039OtherOXFORD
NY00125755Medicaid
5C5092OtherHEALTHYNET
5C5092OtherHEALTHYNET
NY00125755Medicaid