Healthcare Provider Details

I. General information

NPI: 1528194255
Provider Name (Legal Business Name): WILSON LIAO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 08/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 SPRUCE ST
SAN FRANCISCO CA
94118-2616
US

IV. Provider business mailing address

515 SPRUCE ST
SAN FRANCISCO CA
94118-2616
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-4701
  • Fax: 415-502-4126
Mailing address:
  • Phone: 415-476-4701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA89988
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: