Provider Demographics
NPI:1124047063
Name:LEIBOWITZ, MATTHEW RICHARD (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RICHARD
Last Name:LEIBOWITZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 WASHINGTON ST
Mailing Address - Street 2:BLUE 401
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02462-1607
Mailing Address - Country:US
Mailing Address - Phone:617-243-6597
Mailing Address - Fax:617-243-6575
Practice Address - Street 1:2014 WASHINGTON ST
Practice Address - Street 2:BLUE 401
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02462-1607
Practice Address - Country:US
Practice Address - Phone:617-243-6597
Practice Address - Fax:617-243-6575
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG82313207RI0200X
MA80315207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G823130Medicaid
CAWG82313AMedicare PIN
CAG68620Medicare UPIN