Healthcare Provider Details

I. General information

NPI: 1104875483
Provider Name (Legal Business Name): XIAO DA LIU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 12/07/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 TEC ST
HICKSVILLE NY
11801-3618
US

IV. Provider business mailing address

152 73RD ST
BROOKLYN NY
11209-2202
US

V. Phone/Fax

Practice location:
  • Phone: 516-478-9303
  • Fax: 516-932-3672
Mailing address:
  • Phone: 718-836-6964
  • Fax: 718-836-6964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA174112-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: