Basic Information
| Provider Information | |||||||||
| NPI: | 1366624330 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIEDTKE | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5546 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802175546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014753500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4650 HARRISON BLVD | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844034303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014753010 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2007 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 20A12096 | CA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | OP60582410 | WA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 12168421-1204 | UT | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1366624330 | 05 | UT | MEDICAID | P01526646 | 01 | WA | RR MEDICARE | OTHER |