Healthcare Provider Details

I. General information

NPI: 1013236876
Provider Name (Legal Business Name): JERRY T LIU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2010
Last Update Date: 05/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 UNION SQ E STE 4G
NEW YORK NY
10003-3314
US

IV. Provider business mailing address

10 UNION SQ E SUITE 4G
NEW YORK NY
10003
US

V. Phone/Fax

Practice location:
  • Phone: 212-844-8409
  • Fax: 212-844-6556
Mailing address:
  • Phone: 212-844-8409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number265813
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: