Provider Demographics
NPI:1083858518
Name:LIESER, GREGORY CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:CHARLES
Last Name:LIESER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3600 GASTON AVE
Mailing Address - Street 2:SUITE 1205
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1800
Mailing Address - Country:US
Mailing Address - Phone:972-961-9482
Mailing Address - Fax:214-696-4190
Practice Address - Street 1:6460 NAAMAN FOREST BLVD
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75044-5601
Practice Address - Country:US
Practice Address - Phone:972-494-6764
Practice Address - Fax:972-494-6893
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXQ3726208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX348171501Medicaid
TX348171502Medicaid
TX421364YND4Medicare PIN
TX348171501Medicaid