Provider Demographics
NPI:1720153885
Name:LIESKOVSKY, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:LIESKOVSKY
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 1:1441 EASTLAKE AVE
Mailing Address - Street 2:SUITE 7416
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-0177
Mailing Address - Country:US
Mailing Address - Phone:323-865-3700
Mailing Address - Fax:323-865-0120
Practice Address - Street 1:1441 EASTLAKE AVE
Practice Address - Street 2:SUITE 7416
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0177
Practice Address - Country:US
Practice Address - Phone:323-865-3700
Practice Address - Fax:323-865-0120
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35090208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A27681Medicare UPIN