Provider Demographics
NPI:1194184861
Name:JIMMY LIU, M.D., P.A.
Entity Type:Organization
Organization Name:JIMMY LIU, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, MD
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:CHENG-YI
Authorized Official - Last Name:LIU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-759-9819
Mailing Address - Street 1:21301 S TAMIAMI TRL
Mailing Address - Street 2:SUITE 320 PMB 222
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-2942
Mailing Address - Country:US
Mailing Address - Phone:239-345-8001
Mailing Address - Fax:
Practice Address - Street 1:24301 WALDEN CENTER DR STE 300
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-4965
Practice Address - Country:US
Practice Address - Phone:239-345-8001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-23
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102334300Medicaid