Healthcare Provider Details

I. General information

NPI: 1235766858
Provider Name (Legal Business Name): JACK LIU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27005 76TH AVE
NEW HYDE PARK NY
11040-1402
US

IV. Provider business mailing address

182 E 210TH ST BSMT
BRONX NY
10467-2411
US

V. Phone/Fax

Practice location:
  • Phone: 718-470-4557
  • Fax:
Mailing address:
  • Phone: 347-951-5421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number315955
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: