Provider Demographics
NPI:1750378691
Name:LIEBLONG, JIM B (OD)
Entity type:Individual
Prefix:DR
First Name:JIM
Middle Name:B
Last Name:LIEBLONG
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 1:2800 W MAIN
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801
Mailing Address - Country:US
Mailing Address - Phone:479-968-2020
Mailing Address - Fax:479-968-8803
Practice Address - Street 1:2800 W MAIN
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801
Practice Address - Country:US
Practice Address - Phone:479-968-2020
Practice Address - Fax:479-968-8803
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2265152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR103901722Medicaid
AR16617000041OtherQUALCHOICE
AR16617000041OtherQUALCHOICE
AR49128Medicare ID - Type Unspecified