Provider Demographics
NPI:1083675011
Name:LIEPERT, DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:LIEPERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10001 W INNOVATION DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4851
Mailing Address - Country:US
Mailing Address - Phone:888-938-3838
Mailing Address - Fax:888-919-1083
Practice Address - Street 1:53760 GENERATIONS DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1539
Practice Address - Country:US
Practice Address - Phone:574-500-2010
Practice Address - Fax:888-919-1083
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068512B207Y00000X, 207Y00000X
IN01068512A207YS0012X, 207YS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Yes207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN899690300Medicaid
WI1083675011Medicaid
IN200987130Medicaid
MNF90314Medicare UPIN
MN899690300Medicaid
IN200987130Medicaid