Healthcare Provider Details

I. General information

NPI: 1164452546
Provider Name (Legal Business Name): WIEKE H LIEM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17601 17TH ST # 10
TUSTIN CA
92780-1949
US

IV. Provider business mailing address

17601 17TH ST # 110
TUSTIN CA
92780-1949
US

V. Phone/Fax

Practice location:
  • Phone: 714-790-0005
  • Fax: 714-699-2444
Mailing address:
  • Phone: 714-790-0005
  • Fax: 714-699-2444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG70387
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: