Healthcare Provider Details

I. General information

NPI: 1710583927
Provider Name (Legal Business Name): WEITAO LIU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2020
Last Update Date: 08/31/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NORTHEAST MEDICAL GROUP, INC. 20 YORK STREET, CB-2041
NEW HAVEN CT
06510-3220
US

IV. Provider business mailing address

NORTHEAST MEDICAL GROUP, INC. 20 YORK STREET, CB-329
NEW HAVEN CT
06510-3220
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-4748
  • Fax: 203-688-4740
Mailing address:
  • Phone: 36-884-7482
  • Fax: 203-688-4740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number285490
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number75733
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: