Provider Demographics
NPI:1184620916
Name:LIEBLICH, JEFFREY MARTIN (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MARTIN
Last Name:LIEBLICH
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 1:1971 2ND ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-3174
Mailing Address - Country:US
Mailing Address - Phone:847-432-5510
Mailing Address - Fax:847-432-5526
Practice Address - Street 1:1971 2ND ST
Practice Address - Street 2:SUITE 100
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-3174
Practice Address - Country:US
Practice Address - Phone:847-432-5510
Practice Address - Fax:847-432-5526
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036047697207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL640940Medicare PIN
ILD93803Medicare UPIN