Provider Demographics
NPI:1548217987
Name:LIUDAHL, JAMIE J (DO)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:J
Last Name:LIUDAHL
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 1:100 MAC LANE
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-0758
Mailing Address - Country:US
Mailing Address - Phone:605-224-5901
Mailing Address - Fax:605-945-5296
Practice Address - Street 1:100 MAC LANE
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-0758
Practice Address - Country:US
Practice Address - Phone:605-224-5901
Practice Address - Fax:605-945-5296
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5660207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5608410Medicaid
SD100797Medicare ID - Type Unspecified
SD5608410Medicaid