Provider Demographics
NPI:1194897132
Name:LIEBOWITZ, ELLEN BETH (OD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:BETH
Last Name:LIEBOWITZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 B PIONEER AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95776
Mailing Address - Country:US
Mailing Address - Phone:530-661-0300
Mailing Address - Fax:
Practice Address - Street 1:421 PIONEER AVE STE B
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95776-4948
Practice Address - Country:US
Practice Address - Phone:530-661-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA 7260T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0072600Medicaid
CASD0072600Medicaid
HK0162ZMedicare PIN
CAML0697548OtherDEA NUMBER