Provider Demographics
NPI:1225117518
Name:LIESEMEYER, BRETT H (OD)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:H
Last Name:LIESEMEYER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3403 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-2112
Mailing Address - Country:US
Mailing Address - Phone:660-826-6161
Mailing Address - Fax:660-826-8197
Practice Address - Street 1:3403 W 10TH ST
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2112
Practice Address - Country:US
Practice Address - Phone:660-826-6161
Practice Address - Fax:660-826-8197
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02629152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO312338908Medicaid
T42530Medicare UPIN
MO312338908Medicaid
MO0000795Medicare PIN
MO410014549Medicare PIN