Provider Demographics
NPI:1316352024
Name:ZIMA, LIESEL (MD)
Entity type:Individual
Prefix:DR
First Name:LIESEL
Middle Name:
Last Name:ZIMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LIESEL
Other - Middle Name:M
Other - Last Name:UNGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3412 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4624
Mailing Address - Country:US
Mailing Address - Phone:269-329-5860
Mailing Address - Fax:
Practice Address - Street 1:3412 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024
Practice Address - Country:US
Practice Address - Phone:269-329-5860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105254207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301105254OtherMICHIGAN MEDICAL LICENSE NUMBER