1437126034 NPI number — DR. EDWARD C LIU

Table of content: DR. EDWARD C LIU (NPI 1437126034)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437126034 NPI number — DR. EDWARD C LIU

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIU
Provider First Name:
EDWARD
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1437126034
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 610393
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75261-0393
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-291-6187
Provider Business Mailing Address Fax Number:
903-237-1810

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
709 HOLLYBROOK DR
Provider Second Line Business Practice Location Address:
SUITE 3401
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75605-2411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-753-1778
Provider Business Practice Location Address Fax Number:
903-753-7202
Provider Enumeration Date:
03/02/2006

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: 207XX0005X , with the licence number:  F1752 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 130191308 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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