=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114489002
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VIVIAN LIU QIN MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2019
-----------------------------------------------------
Last Update Date | 09/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 STEIN PLZ STE 2-273
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90095-2688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-794-9442
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5767 W CENTURY BLVD STE 400
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90045-5631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207WX0009X
-----------------------------------------------------
Taxonomy Name | Glaucoma Specialist (Ophthalmology) Physician
-----------------------------------------------------
License Number | A185849
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------