Provider Demographics
NPI:1578632485
Name:LIE, KAM S (MD)
Entity Type:Individual
Prefix:MR
First Name:KAM
Middle Name:S
Last Name:LIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:230 HIGHWAY 5 N STE 20
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-3031
Mailing Address - Country:US
Mailing Address - Phone:870-425-6212
Mailing Address - Fax:870-508-6896
Practice Address - Street 1:230 HIGHWAY 5 N STE 20
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3031
Practice Address - Country:US
Practice Address - Phone:870-425-6212
Practice Address - Fax:870-508-6896
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-0460207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5J849OtherAR BC/BS
AR5J849OtherMEDICARE
AR130001001Medicaid
G12501Medicare UPIN