Provider Demographics
NPI:1265449730
Name:LIAO, JUDY CHIA-TI (OD)
Entity Type:Individual
Prefix:DR
First Name:JUDY
Middle Name:CHIA-TI
Last Name:LIAO
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 1:631 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-2801
Mailing Address - Country:US
Mailing Address - Phone:213-680-0404
Mailing Address - Fax:213-680-2853
Practice Address - Street 1:631 N BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-2801
Practice Address - Country:US
Practice Address - Phone:213-680-0404
Practice Address - Fax:213-680-2853
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 11694T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0116940Medicaid
CAWY216Medicare PIN
CASD0116940Medicaid