Provider Demographics
NPI:1013650951
Name:LIEBERMAN, ETHAN SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:SCOTT
Last Name:LIEBERMAN
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:PO BOX 980257
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-0257
Mailing Address - Country:US
Mailing Address - Phone:804-828-9783
Mailing Address - Fax:
Practice Address - Street 1:147 N BRENT ST
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2809
Practice Address - Country:US
Practice Address - Phone:818-719-2706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-19
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0116036266207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program