Healthcare Provider Details

I. General information

NPI: 1568730885
Provider Name (Legal Business Name): GRACE LIU MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2011
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 N. MAIN STREET STE 115
SANTA ANA CA
92705-6638
US

IV. Provider business mailing address

3991 MACARTHUR BLVD STE 228
NEWPORT BEACH CA
92660-3009
US

V. Phone/Fax

Practice location:
  • Phone: 714-571-0228
  • Fax: 714-571-0167
Mailing address:
  • Phone: 949-863-0988
  • Fax: 949-863-0088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA61446
License Number StateCA

VIII. Authorized Official

Name: GRACE LIU
Title or Position: OWNER
Credential: MD
Phone: 714-571-0228