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General NPI Number Information
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NPI Number | 1003815291
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Entity Type | Individual
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Provider Name | JAMES G LIESEN DO
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Gender | Male
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Dates
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Enumeration Date | 07/19/2005
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Last Update Date | 02/23/2017
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Provider Practice Location Address
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Address Line | 1195 N OAKLAND AVE SUITE 2
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City | BOLIVAR
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State | MO
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Zip | 65613-8095
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Country | US
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Telephone | 417-777-2121
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Fax | 417-777-2854
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Provider Business Mailing Address
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Address Line | 1500 N OAKLAND AVE
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City | BOLIVAR
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State | MO
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Zip | 65613-3011
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Country | US
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Telephone | 417-328-6501
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Fax | 417-328-6338
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 2101
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License Number State | WV
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 2008032320
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License Number State | MO
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