Provider Demographics
NPI:1336181643
Name:LIEBERMAN, NATHAN A (OD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:A
Last Name:LIEBERMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635A OWEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3425
Mailing Address - Country:US
Mailing Address - Phone:910-483-2020
Mailing Address - Fax:910-483-0311
Practice Address - Street 1:1635A OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3425
Practice Address - Country:US
Practice Address - Phone:910-483-2020
Practice Address - Fax:910-483-0311
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1499152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890904UMedicaid
NC0906GOtherBCBS
NC890904UMedicaid
NCU46399Medicare UPIN