Provider Demographics
NPI:1407853211
Name:LIETZAU, CAROL L (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:LIETZAU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:L
Other - Last Name:JOHANSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:824 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTEVIDEO
Mailing Address - State:MN
Mailing Address - Zip Code:56265-1629
Mailing Address - Country:US
Mailing Address - Phone:320-269-6435
Mailing Address - Fax:320-269-4494
Practice Address - Street 1:824 N 11TH ST
Practice Address - Street 2:
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265-1629
Practice Address - Country:US
Practice Address - Phone:320-269-6435
Practice Address - Fax:320-269-4494
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22399207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN716792000Medicaid
MN716792000Medicaid
MN80013778Medicare PIN