Provider Demographics
NPI:1205613783
Name:LIEBERENZ, TIMOTHY JOSEPH (OD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:LIEBERENZ
Suffix:
Gender:M
Credentials:OD
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 1082
Mailing Address - Street 2:
Mailing Address - City:MERLIN
Mailing Address - State:OR
Mailing Address - Zip Code:97532-1082
Mailing Address - Country:US
Mailing Address - Phone:541-279-4792
Mailing Address - Fax:
Practice Address - Street 1:8495 CRATER LAKE HWY
Practice Address - Street 2:
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503-3011
Practice Address - Country:US
Practice Address - Phone:541-826-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORATI4707152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist