Provider Demographics
NPI:1578827499
Name:CLOSE, LIESL (MD)
Entity Type:Individual
Prefix:
First Name:LIESL
Middle Name:
Last Name:CLOSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 PARNASSUS AVE RM M779
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2204
Mailing Address - Country:US
Mailing Address - Phone:415-353-7500
Mailing Address - Fax:
Practice Address - Street 1:1411 E 31ST ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-1092
Practice Address - Country:US
Practice Address - Phone:415-353-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR73227208600000X
IAR-9872282N00000X
CAA174945207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA174945OtherMEDICAL LICENSE
AZR73227OtherARIZONA MEDICAL BOARD