Provider Demographics
NPI:1861501058
Name:DIDRIKSEN, LIZBETH HOEPLI (MD)
Entity Type:Individual
Prefix:DR
First Name:LIZBETH
Middle Name:HOEPLI
Last Name:DIDRIKSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2160 S STATE ROUTE 157
Mailing Address - Street 2:SUITE B
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1720
Mailing Address - Country:US
Mailing Address - Phone:618-692-1212
Mailing Address - Fax:618-205-4068
Practice Address - Street 1:2160 S STATE ROUTE 157
Practice Address - Street 2:SUITE B
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1720
Practice Address - Country:US
Practice Address - Phone:618-692-1212
Practice Address - Fax:618-205-4068
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036078684208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078684Medicaid