Provider Demographics
NPI:1568817716
Name:LIECHTI, DANIEL JACOB (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JACOB
Last Name:LIECHTI
Suffix:
Gender:M
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:PO BOX 6850
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-6850
Mailing Address - Country:US
Mailing Address - Phone:605-341-1414
Mailing Address - Fax:
Practice Address - Street 1:2201 S DOUGLAS HWY STE 120
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-5408
Practice Address - Country:US
Practice Address - Phone:800-446-9556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY14803A207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine