1033102744 NPI number — DR. INGRID Y LIU DO

Table of content: DR. INGRID Y LIU DO (NPI 1033102744)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033102744 NPI number — DR. INGRID Y LIU DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIU
Provider First Name:
INGRID
Provider Middle Name:
Y
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033102744
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
917 S OAK PARK AVE STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60304-1950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-386-3080
Provider Business Mailing Address Fax Number:
708-386-3084

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
917 S OAK PARK AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60304-1950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-386-3080
Provider Business Practice Location Address Fax Number:
708-386-3084
Provider Enumeration Date:
08/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  036098244 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1033102744 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 036098244 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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