Provider Demographics
NPI:1073729257
Name:WIEKE H LIEM, M.D.,INC.
Entity Type:Organization
Organization Name:WIEKE H LIEM, M.D.,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WIEKE
Authorized Official - Middle Name:H
Authorized Official - Last Name:LIEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-538-8556
Mailing Address - Street 1:1506 E CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-2231
Mailing Address - Country:US
Mailing Address - Phone:714-538-8556
Mailing Address - Fax:714-538-1082
Practice Address - Street 1:17601 17TH ST STE 110
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-1949
Practice Address - Country:US
Practice Address - Phone:714-790-0005
Practice Address - Fax:714-538-1082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70387207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG70387OtherMEDICAL LICENSE
CA00G703871Medicaid
CAG70387Medicare PIN
CAF10214Medicare UPIN