Healthcare Provider Details

I. General information

NPI: 1679128482
Provider Name (Legal Business Name): JIA YU LIU OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NANCY YU LIU DO

II. Dates (important events)

Enumeration Date: 08/08/2019
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 JEFFERSON PARK AVE
CHARLOTTESVILLE VA
22903-3363
US

IV. Provider business mailing address

PO BOX 9007
CHARLOTTESVILLE VA
22906-9007
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-5485
  • Fax: 434-244-9436
Mailing address:
  • Phone: 434-295-1000
  • Fax: 434-972-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODTG00706
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618002768
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: