Healthcare Provider Details

I. General information

NPI: 1073544466
Provider Name (Legal Business Name): REN-CHANG LIU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CHILD STREET
JACKSONVILLE FL
32214
US

IV. Provider business mailing address

3146 COUNTRY CLUB BLVD
ORANGE PARK FL
32073-5731
US

V. Phone/Fax

Practice location:
  • Phone: 904-542-7744
  • Fax:
Mailing address:
  • Phone: 904-272-2240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME27525
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number18687
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101031837
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number12551
License Number StateOK
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: