Provider Demographics
NPI:1174582951
Name:LIEBERMAN, KENNETH V (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:V
Last Name:LIEBERMAN
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 1:30 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1915
Mailing Address - Country:US
Mailing Address - Phone:551-996-8228
Mailing Address - Fax:551-996-5397
Practice Address - Street 1:30 PROSPECT AVE
Practice Address - Street 2:HUMC - PEDIATRIC CENTER
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1914
Practice Address - Country:US
Practice Address - Phone:551-996-8228
Practice Address - Fax:551-996-5397
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA072707002080P0210X
NY1350652080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00634193 046Medicaid
051590DHKOtherPIN
NJ0923702Medicaid
B13704Medicare UPIN
35690100Medicare ID - Type Unspecified