Provider Demographics
NPI:1982243432
Name:LIBERTY, KEVIN DOUGLAS (DPM)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DOUGLAS
Last Name:LIBERTY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:709 SPRING VALLEY RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-7614
Practice Address - Country:US
Practice Address - Phone:262-767-6020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC007059213E00000X
WI1305213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100224481Medicaid