Provider Demographics
NPI:1477649341
Name:LIEBMAN, BRAD GORDON (OD)
Entity type:Individual
Prefix:DR
First Name:BRAD
Middle Name:GORDON
Last Name:LIEBMAN
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 1:862 E JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-7505
Mailing Address - Country:US
Mailing Address - Phone:631-673-5010
Mailing Address - Fax:631-673-5014
Practice Address - Street 1:862 E JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-7505
Practice Address - Country:US
Practice Address - Phone:631-673-5010
Practice Address - Fax:631-673-5014
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT003655152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT49036Medicare UPIN
NYA400003225Medicare PIN
NYC32302Medicare PIN