Provider Demographics
NPI:1881742047
Name:LIEPA, DAGMAR I (MD)
Entity type:Individual
Prefix:
First Name:DAGMAR
Middle Name:I
Last Name:LIEPA
Suffix:
Gender:
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:PO BOX 52
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91408-0052
Mailing Address - Country:US
Mailing Address - Phone:818-904-9008
Mailing Address - Fax:818-994-4491
Practice Address - Street 1:14407 HAMLIN ST
Practice Address - Street 2:STE A
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-6200
Practice Address - Country:US
Practice Address - Phone:818-904-9008
Practice Address - Fax:818-994-4491
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG478892083A0300X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G478891Medicaid
CAG47889Medicare PIN