Healthcare Provider Details

I. General information

NPI: 1700856671
Provider Name (Legal Business Name): JACOB CHUA LIAO ONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 FOXTRAIL DR SUITE 200
LOVELAND CO
80538-9088
US

IV. Provider business mailing address

1625 FOXTRAIL DR SUITE 200
LOVELAND CO
80538-9088
US

V. Phone/Fax

Practice location:
  • Phone: 970-490-4209
  • Fax:
Mailing address:
  • Phone: 970-490-4209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number37327
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number37327
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number37327
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: