Healthcare Provider Details

I. General information

NPI: 1548965866
Provider Name (Legal Business Name): JOANNA LIU O.D., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 12/13/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4738 BROADWAY
NEW YORK NY
10040-1103
US

IV. Provider business mailing address

4738 BROADWAY
NEW YORK NY
10040-1103
US

V. Phone/Fax

Practice location:
  • Phone: 646-661-7615
  • Fax:
Mailing address:
  • Phone: 646-661-7615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number009764
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: