Basic Information
| Provider Information | |||||||||
| NPI: | 1518931567 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | LIBERATORE | ||||||||
| FirstName: | CARLA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 251 SALINA MEADOWS PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132124516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154642000 | ||||||||
| FaxNumber: | 3154642010 | ||||||||
| Practice Location | |||||||||
| Address1: | 4214 MEDICAL CENTER DR | ||||||||
| Address2: | SUITE 214 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153294968 | ||||||||
| FaxNumber: | 3153294964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 06/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 210806 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 01866279 | 05 | NY | MEDICAID |