Healthcare Provider Details

I. General information

NPI: 1578827499
Provider Name (Legal Business Name): LIESL CLOSE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 10/14/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 E 31ST ST
OAKLAND CA
94602-1092
US

IV. Provider business mailing address

505 PARNASSUS AVE RM M779
SAN FRANCISCO CA
94143-2204
US

V. Phone/Fax

Practice location:
  • Phone: 415-353-7500
  • Fax:
Mailing address:
  • Phone: 415-353-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberR-9872
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberA174945
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberR73227
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: