Provider Demographics
NPI:1609024447
Name:LIEB, MICHAEL D (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:LIEB
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:609-267-1004
Mailing Address - Fax:609-267-1044
Practice Address - Street 1:212 CREEK CROSSING BLVD
Practice Address - Street 2:
Practice Address - City:HAINESPORT
Practice Address - State:NJ
Practice Address - Zip Code:08036-2766
Practice Address - Country:US
Practice Address - Phone:609-267-1004
Practice Address - Fax:609-267-1044
Is Sole Proprietor?:No
Enumeration Date:2008-09-05
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MB091143002086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0422185Medicaid