Provider Demographics
NPI:1649238130
Name:LIU, JIANDONG (MD)
Entity Type:Individual
Prefix:
First Name:JIANDONG
Middle Name:
Last Name:LIU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2902 E VIRGINIA AVE
Mailing Address - Street 2:#12
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-2159
Mailing Address - Country:US
Mailing Address - Phone:626-676-0172
Mailing Address - Fax:
Practice Address - Street 1:2902 E VIRGINIA AVE
Practice Address - Street 2:#12
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91791-2159
Practice Address - Country:US
Practice Address - Phone:626-676-0172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45913207R00000X
CAA96949207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34808800Medicaid
WI34808800Medicaid