Provider Demographics
NPI:1942406699
Name:LIEBERMAN, THEODORE W (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:W
Last Name:LIEBERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY083922207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00125755Medicaid
434061Medicare PIN
NY00125755Medicaid