Provider Demographics
NPI:1568817716
Name:LIECHTI, DANIEL JACOB (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JACOB
Last Name:LIECHTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:744 S WEBSTER AVE
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301
Mailing Address - Country:US
Mailing Address - Phone:920-433-7860
Mailing Address - Fax:920-433-6090
Practice Address - Street 1:1970 S RIDGE RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-4125
Practice Address - Country:US
Practice Address - Phone:920-430-4888
Practice Address - Fax:920-430-4889
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI83448-20207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery