Provider Demographics
NPI:1659375178
Name:LIEU, CHONG (MD)
Entity Type:Individual
Prefix:
First Name:CHONG
Middle Name:
Last Name:LIEU
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 1:930 W WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8811
Mailing Address - Country:US
Mailing Address - Phone:704-663-7500
Mailing Address - Fax:704-799-2613
Practice Address - Street 1:930 W WILSON AVE
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8811
Practice Address - Country:US
Practice Address - Phone:704-663-7500
Practice Address - Fax:704-799-2613
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22139207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8951921Medicaid
NC8951921Medicaid
NCC85527Medicare UPIN