Healthcare Provider Details

I. General information

NPI: 1033102744
Provider Name (Legal Business Name): INGRID Y LIU DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 03/22/2023
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 S OAK PARK AVE STE B
OAK PARK IL
60304-1950
US

IV. Provider business mailing address

917 S OAK PARK AVE STE B
OAK PARK IL
60304-1950
US

V. Phone/Fax

Practice location:
  • Phone: 708-386-3080
  • Fax: 708-386-3084
Mailing address:
  • Phone: 708-386-3080
  • Fax: 708-386-3084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036098244
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: