Basic Information
| Provider Information | |||||||||
| NPI: | 1245220615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIEBOW | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 910 | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 013020910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137728500 | ||||||||
| FaxNumber: | 4137728900 | ||||||||
| Practice Location | |||||||||
| Address1: | 382 CANAL ST | ||||||||
| Address2: | |||||||||
| City: | BRATTLEBORO | ||||||||
| State: | VT | ||||||||
| PostalCode: | 053016617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022540202 | ||||||||
| FaxNumber: | 8022461300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 05/09/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 0560000157 | VT | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 19943 | 01 | VT | BC/BS VT | OTHER | 30007741 | 05 | NH | MEDICAID | OVN0942 | 05 | VT | MEDICAID | 78569 | 01 | VT | MVP | OTHER |