Provider Demographics
NPI:1841399607
Name:LIETTE, TIMOTHY ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:ALLEN
Last Name:LIETTE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:5542 SCHLADE CT
Mailing Address - Street 2:
Mailing Address - City:LIBERTY TWP
Mailing Address - State:OH
Mailing Address - Zip Code:45044-9037
Mailing Address - Country:US
Mailing Address - Phone:513-257-6188
Mailing Address - Fax:513-346-4042
Practice Address - Street 1:1100 E KEMPER RD
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:OH
Practice Address - Zip Code:45246-3321
Practice Address - Country:US
Practice Address - Phone:513-346-7952
Practice Address - Fax:513-346-4042
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2020-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4857T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHU99611Medicare UPIN