Provider Demographics
NPI:1770598443
Name:LIBERMAN, GARY LEE (OD,PHD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:LIBERMAN
Suffix:
Gender:M
Credentials:OD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 HOSPITAL DR STE 201
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-2500
Mailing Address - Country:US
Mailing Address - Phone:707-554-3101
Mailing Address - Fax:707-554-2402
Practice Address - Street 1:127 HOSPITAL DR STE 201
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2500
Practice Address - Country:US
Practice Address - Phone:707-554-3101
Practice Address - Fax:707-554-2402
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4976 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0049762Medicare PIN
CAT09838Medicare UPIN