Healthcare Provider Details

I. General information

NPI: 1417605684
Provider Name (Legal Business Name): GUYU LIU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2022
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 DAVID L GOLDFEIN ST BLDG 23
HOLLOMAN AFB NM
88330-8273
US

IV. Provider business mailing address

280 DAVID L GOLDFEIN ST BLDG 23
HOLLOMAN AIR FORCE BASE NM
88330-8273
US

V. Phone/Fax

Practice location:
  • Phone: 575-572-0723
  • Fax:
Mailing address:
  • Phone: 575-572-0723
  • Fax: 575-572-3182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101279842
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: