Provider Demographics
NPI:1932109253
Name:LIEBERMAN, JEFFREY
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:LIEBERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 S MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-2722
Mailing Address - Country:US
Mailing Address - Phone:716-662-0293
Mailing Address - Fax:716-402-1862
Practice Address - Street 1:3055 SOUTHWESTERN BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1231
Practice Address - Country:US
Practice Address - Phone:716-677-6736
Practice Address - Fax:716-677-6144
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1829182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00040819806OtherUNIVERA
NY300136886OtherRAILROAD MEDICARE
P00420095OtherRAILROAD MEDICARE
NYCRDRA1829183OtherWORKERS COMPENSATION
000523824010OtherBLUE SHIELD OF WESTERN NY
208616656OtherFIDELIS
NY01616022Medicaid
5608639OtherINDEPENDANT HEALTH
5608639OtherINDEPENDANT HEALTH
NYDD3075Medicare ID - Type Unspecified
NYRB4938Medicare PIN