Provider Demographics
NPI:1871562934
Name:LIBERATORE, LISA A (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:LIBERATORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 EAST 85 STREET
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028
Mailing Address - Country:US
Mailing Address - Phone:212-288-2222
Mailing Address - Fax:212-288-8082
Practice Address - Street 1:154 EAST 85 STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028
Practice Address - Country:US
Practice Address - Phone:212-288-2222
Practice Address - Fax:212-288-8082
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189838207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02G112Medicare ID - Type Unspecified
G19135Medicare UPIN