Healthcare Provider Details

I. General information

NPI: 1134706989
Provider Name (Legal Business Name): GARY LIU MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 W KENNEDY BLVD STE 303
TAMPA FL
33609-2257
US

IV. Provider business mailing address

3512 W OBISPO ST
TAMPA FL
33629-7917
US

V. Phone/Fax

Practice location:
  • Phone: 813-419-2067
  • Fax:
Mailing address:
  • Phone: 813-419-2067
  • Fax: 305-703-6558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME173028
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD481609
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: