Provider Demographics
NPI:1275649238
Name:LIU, CRAIG (OD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:
Last Name:LIU
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 C AVE
Mailing Address - Street 2:STE B
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118
Mailing Address - Country:US
Mailing Address - Phone:619-435-3333
Mailing Address - Fax:619-435-3397
Practice Address - Street 1:171 C AVE
Practice Address - Street 2:STE B
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-4411
Practice Address - Country:US
Practice Address - Phone:619-435-3333
Practice Address - Fax:619-435-3397
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11175152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA11175Medicare PIN
CACV790AMedicare PIN
CA95750Medicare UPIN