Provider Demographics
NPI:1326031048
Name:JEN, LIAN (DO PA)
Entity Type:Individual
Prefix:DR
First Name:LIAN
Middle Name:
Last Name:JEN
Suffix:
Gender:M
Credentials:DO PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3089 TAMIAMI TRAIL
Mailing Address - Street 2:SUITE B
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952
Mailing Address - Country:US
Mailing Address - Phone:941-627-9768
Mailing Address - Fax:941-627-2785
Practice Address - Street 1:3089 TAMIAMI TRAIL
Practice Address - Street 2:SUITE B
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952
Practice Address - Country:US
Practice Address - Phone:941-627-9768
Practice Address - Fax:941-627-2785
Is Sole Proprietor?:No
Enumeration Date:2005-08-28
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7724208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273460500Medicaid
FL49234OtherBCBS
FLG09374Medicare UPIN
FL49234OtherBCBS
FL273460500Medicaid