MEDICARE: DR. KATRINA RENEE LIESKE OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	5578TG	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0030FG	OTHER	TX	BCBS PROVIDER #

General Provider Information

NPI Number	:	1477542470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATRINA RENEE LIESKE OD

Provider Business Mailing Address
First Line	:	5412 BOAT CLUB RD STE 150
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-1205
Country	:	US
Telephone Number	:	817-546-9000
Fax Number	:

Provider Business Practice Location Address
First Line	:	5412 BOAT CLUB RD STE 150
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-1205
Country	:	US
Telephone Number	:	817-546-9000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2005
Last Update Date	:	12/28/2021

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