Provider Demographics
NPI:1740271782
Name:LIEBURN, DAVID CLARK (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:CLARK
Last Name:LIEBURN
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 1:3172 ATLANTIS DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-7385
Mailing Address - Country:US
Mailing Address - Phone:920-434-9425
Mailing Address - Fax:
Practice Address - Street 1:2585 LINEVILLE RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-7122
Practice Address - Country:US
Practice Address - Phone:920-662-9450
Practice Address - Fax:920-662-1912
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1748-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38515700Medicaid
410029527OtherRAILROAD MEDICARE
WI38515700Medicaid
T62604Medicare UPIN