Provider Demographics
NPI:1699835504
Name:LIESER, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LIESER
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 1:600 TORONTO AVE APT 18
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78503-3071
Mailing Address - Country:US
Mailing Address - Phone:956-687-7151
Mailing Address - Fax:956-668-8346
Practice Address - Street 1:540 W 5TH ST
Practice Address - Street 2:350
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5034
Practice Address - Country:US
Practice Address - Phone:432-332-7500
Practice Address - Fax:432-332-7503
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK51422086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX118656105Medicaid
TX8S4850OtherBCBS
TXP00326685OtherRAILROAD
TXP00326685OtherRAILROAD
TX8S4850OtherBCBS
TXG42150Medicare UPIN