Provider Demographics
NPI:1245243484
Name:LIE, ARIADNE GUINEVERE (MD)
Entity Type:Individual
Prefix:
First Name:ARIADNE
Middle Name:GUINEVERE
Last Name:LIE
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 1:5800 HOLLIS ST
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-2016
Mailing Address - Country:US
Mailing Address - Phone:510-806-2238
Mailing Address - Fax:
Practice Address - Street 1:5800 HOLLIS ST
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-2016
Practice Address - Country:US
Practice Address - Phone:510-806-2238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252084207R00000X, 208000000X
CAC175923208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05168438Medicaid
COST11.30.10Medicare PIN