Basic Information
| Provider Information | |||||||||
| NPI: | 1083858518 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIESER | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 GASTON AVE | ||||||||
| Address2: | SUITE 1205 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752461800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729619482 | ||||||||
| FaxNumber: | 2146964190 | ||||||||
| Practice Location | |||||||||
| Address1: | 6460 NAAMAN FOREST BLVD | ||||||||
| Address2: | |||||||||
| City: | GARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750445601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724946764 | ||||||||
| FaxNumber: | 9724946893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2009 | ||||||||
| LastUpdateDate: | 06/07/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Q3726 | TX | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 348171501 | 05 | TX | MEDICAID | 348171502 | 05 | TX | MEDICAID |