Healthcare Provider Details

I. General information

NPI: 1265870307
Provider Name (Legal Business Name): SHUJUAN LIU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11109 PARKVIEW PLAZA DR
FORT WAYNE IN
46845-1701
US

IV. Provider business mailing address

5700 SOUTHWYCK BLVD
TOLEDO OH
43614-1509
US

V. Phone/Fax

Practice location:
  • Phone: 260-266-1000
  • Fax: 260-422-0077
Mailing address:
  • Phone: 800-288-8325
  • Fax: 419-866-5453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number01083525A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: