Provider Demographics
NPI:1194864157
Name:LIETZ, KATHERINE (MD PHD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:LIETZ
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-5820
Mailing Address - Fax:239-343-4098
Practice Address - Street 1:9981 S HEALTHPARK DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3618
Practice Address - Country:US
Practice Address - Phone:239-343-5820
Practice Address - Fax:239-343-4098
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101252774207RA0001X
IL127613207RC0000X
FLME166042207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1194864157Medicaid