Healthcare Provider Details

I. General information

NPI: 1295745172
Provider Name (Legal Business Name): PETER LIU, MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 08/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15107 VANOWEN ST
VAN NUYS CA
91405-4542
US

IV. Provider business mailing address

PO BOX 2620
HAYDEN ID
83835-2620
US

V. Phone/Fax

Practice location:
  • Phone: 818-902-2909
  • Fax: 818-902-5713
Mailing address:
  • Phone: 208-676-9080
  • Fax: 208-676-9098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA45712
License Number StateCA

VIII. Authorized Official

Name: DR. PETER YUDT PING LIU
Title or Position: CEO
Credential: M.D.
Phone: 208-676-9080