Provider Demographics
NPI:1144232042
Name:LIDDELL, TRAVIS RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:RICHARD
Last Name:LIDDELL
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 1:911 E 20TH ST
Mailing Address - Street 2:STE 300
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1045
Mailing Address - Country:US
Mailing Address - Phone:605-322-1300
Mailing Address - Fax:
Practice Address - Street 1:2908 E. 26TH ST.
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-4034
Practice Address - Country:US
Practice Address - Phone:605-336-2638
Practice Address - Fax:605-334-3500
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI13909207X00000X
SD8782207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6402660Medicaid
SD6402660Medicaid
SDS107395Medicare PIN