Provider Demographics
NPI:1225042674
Name:LIAO, OTTO (MD)
Entity Type:Individual
Prefix:DR
First Name:OTTO
Middle Name:
Last Name:LIAO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1076 E 1ST ST STE B
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3852
Mailing Address - Country:US
Mailing Address - Phone:714-838-2617
Mailing Address - Fax:
Practice Address - Street 1:1076 E 1ST ST STE B
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3852
Practice Address - Country:US
Practice Address - Phone:714-838-2617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA068959207RA0201X, 2080P0201X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11465065OtherCAQH
CAH12050Medicare UPIN