Provider Demographics
NPI:1003996554
Name:LIU, PHYLLIS A (OD)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:A
Last Name:LIU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 AMITY RD STE 212
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525-2200
Mailing Address - Country:US
Mailing Address - Phone:203-387-0038
Mailing Address - Fax:203-387-0510
Practice Address - Street 1:264 AMITY RD STE 212
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:CT
Practice Address - Zip Code:06525-2200
Practice Address - Country:US
Practice Address - Phone:203-387-0038
Practice Address - Fax:203-387-0510
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002161152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410000521Medicare ID - Type Unspecified
CTU09000Medicare UPIN