Provider Demographics
NPI:1366430605
Name:LIESTER, MITCHELL BRENT (MD)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:BRENT
Last Name:LIESTER
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:PO BOX 302
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-0302
Mailing Address - Country:US
Mailing Address - Phone:719-488-0024
Mailing Address - Fax:719-488-6672
Practice Address - Street 1:153 WASHINGTON ST
Practice Address - Street 2:SUITE 103
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-9181
Practice Address - Country:US
Practice Address - Phone:719-488-0024
Practice Address - Fax:719-488-6672
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO293952084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01293950Medicaid
COA93506Medicare UPIN
CO53851Medicare ID - Type Unspecified