Provider Demographics
NPI:1922067263
Name:LIEBSCHER, GREGORY J (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:LIEBSCHER
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 1:5901 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:COLO SPGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-1941
Mailing Address - Country:US
Mailing Address - Phone:719-634-2503
Mailing Address - Fax:719-634-2686
Practice Address - Street 1:5901 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:COLO SPGS
Practice Address - State:CO
Practice Address - Zip Code:80919-1941
Practice Address - Country:US
Practice Address - Phone:719-634-2503
Practice Address - Fax:719-634-2686
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO33468208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
COLIA35161OtherBLUE SHIELD
CO01334689Medicaid
F45068Medicare UPIN
COC53771Medicare PIN