Provider Demographics
NPI:1316980568
Name:LIEBERMAN, JAY ALAN (DPM)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:ALAN
Last Name:LIEBERMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2964 N STATE ROAD 7
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-5715
Mailing Address - Country:US
Mailing Address - Phone:954-580-4080
Mailing Address - Fax:954-580-4081
Practice Address - Street 1:2964 N STATE ROAD 7
Practice Address - Street 2:SUITE 205
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-5715
Practice Address - Country:US
Practice Address - Phone:954-580-4080
Practice Address - Fax:954-580-4081
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO0001449213E00000X, 213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0410667Medicaid
T55555Medicare UPIN
87806ZMedicare PIN
87806Medicare ID - Type Unspecified