Basic Information
| Provider Information | |||||||||
| NPI: | 1437101904 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIBERMAN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2234 COLONIAL BLVD | ||||||||
| Address2: | ATTN: MANAGED CARE DEPT. | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399317342 | ||||||||
| FaxNumber: | 2399317385 | ||||||||
| Practice Location | |||||||||
| Address1: | 6101 PINE RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341193900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393484123 | ||||||||
| FaxNumber: | 2393484035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 05/06/2016 | ||||||||
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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 | 208600000X | FLME0078783 | FL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00921458 | 01 | FL | RAILROAD MEDICARE | OTHER | P202313 | 01 | FL | OPTIMUM | OTHER | 061640 | 01 | FL | WELLCARE | OTHER | 3314810 | 01 | FL | CIGNA | OTHER | 10M009 | 01 | FL | HEALTHY KIDS PROGRAM THRU COMMUNITY HEALTH PARTNERS, PHO | OTHER | 115988 | 01 | FL | UNIVERSAL | OTHER | 256953100 | 05 | FL | MEDICAID | 4579508 | 01 | FL | AETNA | OTHER | 308519 | 01 | FL | AVMED | OTHER | P307258 | 01 | FL | FREEDOM HEALTH | OTHER |