Healthcare Provider Details

I. General information

NPI: 1881742047
Provider Name (Legal Business Name): DAGMAR I LIEPA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2007
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14407 HAMLIN ST STE A
VAN NUYS CA
91401-6200
US

IV. Provider business mailing address

PO BOX 52
VAN NUYS CA
91408-0052
US

V. Phone/Fax

Practice location:
  • Phone: 818-904-9008
  • Fax: 818-994-4491
Mailing address:
  • Phone: 818-904-9008
  • Fax: 818-994-4491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG47889
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License NumberG47889
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: