Provider Demographics
NPI:1003815291
Name:LIESEN, JAMES G (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:G
Last Name:LIESEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1500 N OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-3011
Mailing Address - Country:US
Mailing Address - Phone:417-328-6501
Mailing Address - Fax:417-328-6338
Practice Address - Street 1:1195 N OAKLAND AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-8095
Practice Address - Country:US
Practice Address - Phone:417-777-2121
Practice Address - Fax:417-777-2854
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV2101208000000X
MO2008032320208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810002037Medicaid
MO152360045Medicare PIN