Provider Demographics
NPI:1184973877
Name:LIBERTY STAR MEDICAL LTD
Entity type:Organization
Organization Name:LIBERTY STAR MEDICAL LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:GATTUSO
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:608-563-4213
Mailing Address - Street 1:1905 CENTER AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-2842
Mailing Address - Country:US
Mailing Address - Phone:608-295-3670
Mailing Address - Fax:866-998-1030
Practice Address - Street 1:1905 CENTER AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-2842
Practice Address - Country:US
Practice Address - Phone:608-563-4213
Practice Address - Fax:866-998-1030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-10
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27454-20261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center