Healthcare Provider Details

I. General information

NPI: 1649238130
Provider Name (Legal Business Name): JIANDONG LIU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 11/29/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2902 E VIRGINIA AVE #12
WEST COVINA CA
91791-2159
US

IV. Provider business mailing address

2902 E VIRGINIA AVE #12
WEST COVINA CA
91791-2159
US

V. Phone/Fax

Practice location:
  • Phone: 626-676-0172
  • Fax:
Mailing address:
  • Phone: 626-676-0172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number45913
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA96949
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: