Provider Demographics
NPI:1457359713
Name:LIEBROSS, IRA (MD)
Entity Type:Individual
Prefix:DR
First Name:IRA
Middle Name:
Last Name:LIEBROSS
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 1:32 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:FLEMINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08822-1504
Mailing Address - Country:US
Mailing Address - Phone:908-782-0722
Mailing Address - Fax:
Practice Address - Street 1:32 CHURCH ST
Practice Address - Street 2:
Practice Address - City:FLEMINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08822-1504
Practice Address - Country:US
Practice Address - Phone:908-782-0722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06405800207Q00000X
NJ64058207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG30416Medicare UPIN
879622Medicare ID - Type Unspecified