Provider Demographics
NPI:1255505715
Name:LIEBEKNECHT, CHARLES LOUIS (DO)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LOUIS
Last Name:LIEBEKNECHT
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 SOUTH BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PENNSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08070-2655
Mailing Address - Country:US
Mailing Address - Phone:856-678-7819
Mailing Address - Fax:
Practice Address - Street 1:370 SOUTH BROADWAY
Practice Address - Street 2:
Practice Address - City:PENNSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08070-2655
Practice Address - Country:US
Practice Address - Phone:856-678-7819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2025-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB01738200208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3918Medicare PIN
NJE06028Medicare UPIN
NJLI41233Medicare Oscar/Certification