Provider Demographics
NPI:1962400952
Name:LIEB, GREGORY A (OD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:LIEB
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 VONDERBURG DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5501
Mailing Address - Country:US
Mailing Address - Phone:813-681-1122
Mailing Address - Fax:813-689-1099
Practice Address - Street 1:3115 W SWANN AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4617
Practice Address - Country:US
Practice Address - Phone:813-492-2020
Practice Address - Fax:813-492-2099
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3354152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20965OtherBLUE CROSS BLUE SHIELD
FL620771500Medicaid
FL7328183OtherAETNA
FL620771500Medicaid