Provider Demographics
NPI:1477542470
Name:LIESKE, KATRINA RENEE (OD)
Entity Type:Individual
Prefix:DR
First Name:KATRINA
Middle Name:RENEE
Last Name:LIESKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:TRINA
Other - Middle Name:
Other - Last Name:LIESKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:5412 BOAT CLUB RD STE 150
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-1205
Mailing Address - Country:US
Mailing Address - Phone:817-546-9000
Mailing Address - Fax:
Practice Address - Street 1:5412 BOAT CLUB RD STE 150
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-1205
Practice Address - Country:US
Practice Address - Phone:817-546-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5578TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0030FGOtherBCBS PROVIDER #
TXU95147Medicare UPIN
TX8A6513Medicare ID - Type Unspecified