Provider Demographics
NPI:1972618924
Name:LIUDAHL, JEFFREY J (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:J
Last Name:LIUDAHL
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 1:100 MAC LANE
Mailing Address - Street 2:AVERA MEDICAL GROUP PIERRE
Mailing Address - City:PIERRES
Mailing Address - State:SD
Mailing Address - Zip Code:57501
Mailing Address - Country:US
Mailing Address - Phone:605-945-5202
Mailing Address - Fax:605-945-5294
Practice Address - Street 1:100 MAC LANE
Practice Address - Street 2:AVERA MEDICAL GROUP PIERRE
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501
Practice Address - Country:US
Practice Address - Phone:605-945-5202
Practice Address - Fax:605-945-5294
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SD1242207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6520325Medicaid
SD6520324Medicaid
SDS103397Medicare PIN
SDS104111Medicare PIN
SD6520325Medicaid