Provider Demographics
NPI:1164452546
Name:LIEM, WIEKE H (MD)
Entity Type:Individual
Prefix:
First Name:WIEKE
Middle Name:H
Last Name:LIEM
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 1:17601 17TH ST # 110
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-1949
Mailing Address - Country:US
Mailing Address - Phone:714-790-0005
Mailing Address - Fax:714-699-2444
Practice Address - Street 1:17601 17TH ST # 10
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-1949
Practice Address - Country:US
Practice Address - Phone:714-790-0005
Practice Address - Fax:714-699-2444
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70387207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G730871Medicaid
CAG70387OtherMEDICAL LICENSE
CA00G730871Medicaid
CAF10214Medicare UPIN