Provider Demographics
NPI:1619945417
Name:LIU, KENNETH A (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:LIU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KENNETH
Other - Middle Name:ANKAI
Other - Last Name:LIU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:27309 MADISON AVE
Mailing Address - Street 2:KAISER PERMANENTE TEMCULA MEDICAL OFFICE BUILDING
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-5685
Mailing Address - Country:US
Mailing Address - Phone:951-302-4209
Mailing Address - Fax:951-302-4517
Practice Address - Street 1:27309 MADISON AVE
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5685
Practice Address - Country:US
Practice Address - Phone:951-302-4209
Practice Address - Fax:951-302-4517
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108761208000000X
CAA98315208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG74511Medicare UPIN