Provider Demographics
NPI:1093767741
Name:BREDESON, LIESL KIRSTEN (MD)
Entity Type:Individual
Prefix:DR
First Name:LIESL
Middle Name:KIRSTEN
Last Name:BREDESON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 FOREST LN STE D-1200
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2571
Mailing Address - Country:US
Mailing Address - Phone:214-365-1150
Mailing Address - Fax:214-363-2477
Practice Address - Street 1:7777 FOREST LN STE D-1200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2571
Practice Address - Country:US
Practice Address - Phone:214-365-1150
Practice Address - Fax:214-363-2477
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3012174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164525101Medicaid
TX164525101Medicaid
TXH30040Medicare UPIN