Healthcare Provider Details

I. General information

NPI: 1104445584
Provider Name (Legal Business Name): XIAO WEI LIU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6278 FOREST AVE
RIDGEWOOD NY
11385-2010
US

IV. Provider business mailing address

6278 FOREST AVE
RIDGEWOOD NY
11385-2010
US

V. Phone/Fax

Practice location:
  • Phone: 929-314-0119
  • Fax: 646-354-7673
Mailing address:
  • Phone: 929-314-0119
  • Fax: 646-354-7673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number337340
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number337340
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: