Healthcare Provider Details

I. General information

NPI: 1942358916
Provider Name (Legal Business Name): EDWARD REGAN LIAO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4618 FOUNTAIN AVE
LOS ANGELES CA
90029-1977
US

IV. Provider business mailing address

950 S GRAND AVE FL 2
LOS ANGELES CA
90015-3999
US

V. Phone/Fax

Practice location:
  • Phone: 323-953-7170
  • Fax:
Mailing address:
  • Phone: 323-669-4346
  • Fax: 323-635-1891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA77570
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: