Provider Demographics
NPI:1649276304
Name:LIEBERMAN, ELLIOTT (MD)
Entity type:Individual
Prefix:DR
First Name:ELLIOTT
Middle Name:
Last Name:LIEBERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:875 OLD COUNTRY RD
Mailing Address - Street 2:STE 301
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-4934
Mailing Address - Country:US
Mailing Address - Phone:516-931-1710
Mailing Address - Fax:516-931-2362
Practice Address - Street 1:875 OLD COUNTRY RD
Practice Address - Street 2:STE 301
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-4934
Practice Address - Country:US
Practice Address - Phone:516-931-1710
Practice Address - Fax:516-931-2362
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133768208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC10880Medicare UPIN
NY52A851Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER