Provider Demographics
NPI:1265445894
Name:LIU, LISEN (MD)
Entity Type:Individual
Prefix:
First Name:LISEN
Middle Name:
Last Name:LIU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13620 38TH AVE 6E
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-4232
Mailing Address - Country:US
Mailing Address - Phone:718-939-2669
Mailing Address - Fax:718-939-2663
Practice Address - Street 1:13625 MAPLE AVE
Practice Address - Street 2:SUITE 201,WISDOM MEDICAL PC
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-3870
Practice Address - Country:US
Practice Address - Phone:718-939-2669
Practice Address - Fax:718-939-2663
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239854207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY20-8142542OtherTAX IDENTIFICATION
NY02819487Medicaid
NY20-8142542OtherTAX IDENTIFICATION