Provider Demographics
NPI:1699742346
Name:LIBERTHSON, RICHARD R (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:R
Last Name:LIBERTHSON
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 1:8 HAWTHORNE PL
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2335
Mailing Address - Country:US
Mailing Address - Phone:617-726-8510
Mailing Address - Fax:617-726-9839
Practice Address - Street 1:8 HAWTHORNE PL
Practice Address - Street 2:SUITE 110
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2335
Practice Address - Country:US
Practice Address - Phone:617-726-8510
Practice Address - Fax:617-726-9839
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA37162207RC0000X, 2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2019671Medicaid
MA700822OtherTUFTS HEALTH PLAN
MAM08708OtherBCBS MA
MA700822OtherTUFTS HEALTH PLAN
MAM08708Medicare ID - Type Unspecified