Healthcare Provider Details

I. General information

NPI: 1083675011
Provider Name (Legal Business Name): DOUGLAS LIEPERT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53760 GENERATIONS DR
SOUTH BEND IN
46635-1539
US

IV. Provider business mailing address

10001 W INNOVATION DR STE 200
MILWAUKEE WI
53226-4851
US

V. Phone/Fax

Practice location:
  • Phone: 574-500-2010
  • Fax: 888-919-1083
Mailing address:
  • Phone: 888-938-3838
  • Fax: 888-919-1083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number01068512B
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number01068512A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: