Provider Demographics
NPI:1114196607
Name:LIU, KWANG-SAN (MD)
Entity Type:Individual
Prefix:
First Name:KWANG-SAN
Middle Name:
Last Name:LIU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:
Other - Last Name:LIU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:550 22ND ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3312
Mailing Address - Country:US
Mailing Address - Phone:503-338-7595
Mailing Address - Fax:
Practice Address - Street 1:550 22ND ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3312
Practice Address - Country:US
Practice Address - Phone:503-338-7595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD28072207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD28072OtherSTATE LICENSE
ORMD28072OtherSTATE LICENSE