Provider Demographics
NPI:1366624330
Name:LIEDTKE, ERIC E (DO)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:E
Last Name:LIEDTKE
Suffix:
Gender:M
Credentials:DO
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 5546
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5546
Mailing Address - Country:US
Mailing Address - Phone:801-475-3500
Mailing Address - Fax:
Practice Address - Street 1:4650 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4303
Practice Address - Country:US
Practice Address - Phone:801-475-3010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A12096208600000X
WAOP60582410208600000X
UT12168421-1204208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1366624330Medicaid
WAP01526646OtherRR MEDICARE
WA1366624330Medicaid