Provider Demographics
NPI:1578758207
Name:MITCHELL B. LIESTER, M.D., P.C.
Entity Type:Organization
Organization Name:MITCHELL B. LIESTER, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:LIESTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-488-0024
Mailing Address - Street 1:PO BOX 302
Mailing Address - Street 2:153 N. WASHINGTON STREET, SUITE 103
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-0302
Mailing Address - Country:US
Mailing Address - Phone:719-488-0024
Mailing Address - Fax:719-488-6672
Practice Address - Street 1:153 WASHINGTON ST STE 103
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-9181
Practice Address - Country:US
Practice Address - Phone:719-488-0024
Practice Address - Fax:719-488-6672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29395261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
COA93506Medicare UPIN