Provider Demographics
NPI:1073773800
Name:LIETZ, EHREN (IDC)
Entity Type:Individual
Prefix:MR
First Name:EHREN
Middle Name:
Last Name:LIETZ
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35000 GUADALCANAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92140-5599
Mailing Address - Country:US
Mailing Address - Phone:619-524-8397
Mailing Address - Fax:
Practice Address - Street 1:35000 GUADALCANAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92140-5599
Practice Address - Country:US
Practice Address - Phone:619-524-8397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDCOtherIDC