Provider Demographics
NPI:1184608770
Name:LIBERTIN, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:LIBERTIN
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 1:6229 N APPLECROSS RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44143-3726
Mailing Address - Country:US
Mailing Address - Phone:440-646-1651
Mailing Address - Fax:440-646-1651
Practice Address - Street 1:6229 N APPLECROSS RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44143-3726
Practice Address - Country:US
Practice Address - Phone:440-646-1651
Practice Address - Fax:440-646-1651
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35055788L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1879024002OtherCIGNA
OH341865880001OtherMEDICAL MUTUAL
OH50875OtherQUALCHOICE
OH000000140712OtherANTHEM
OH2060479Medicaid
OH341865880028OtherCARESOURCE
OH341865880028OtherCARESOURCE
OH0632622Medicare PIN