Healthcare Provider Details

I. General information

NPI: 1700975976
Provider Name (Legal Business Name): DAVID M K I LIU MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 09/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 SOUTH AVE
SOUTH LAKE TAHOE CA
96150-7025
US

IV. Provider business mailing address

1111 EMERALD BAY RD
SOUTH LAKE TAHOE CA
96150-6207
US

V. Phone/Fax

Practice location:
  • Phone: 530-543-5623
  • Fax: 530-541-5738
Mailing address:
  • Phone: 530-543-5659
  • Fax: 530-541-8723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC56003
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC56003
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number13414
License Number StateHI
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number13414
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: