1073609715 NPI number — DR. JEANNY M LIU-WU OD

Table of content: DR. JEANNY M LIU-WU OD (NPI 1073609715)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073609715 NPI number — DR. JEANNY M LIU-WU OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIU-WU
Provider First Name:
JEANNY
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1073609715
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3781 FAIRWAY DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-735-3477
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PEARLE VISION
Provider Second Line Business Practice Location Address:
3001 WHITE BEAR AVE. NO., SUITE 1050
Provider Business Practice Location Address City Name:
ST. PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-770-3923
Provider Business Practice Location Address Fax Number:
651-770-5316
Provider Enumeration Date:
10/04/2006

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: 152W00000X , with the licence number:  2339 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 12342 . This is a "EYE MED / COLE VISION" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 140725200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3C313WU . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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