Provider Demographics
NPI:1700856671
Name:LIAO ONG, JACOB CHUA (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:CHUA
Last Name:LIAO ONG
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 1:1625 FOXTRAIL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9088
Mailing Address - Country:US
Mailing Address - Phone:970-490-4209
Mailing Address - Fax:
Practice Address - Street 1:1625 FOXTRAIL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-9088
Practice Address - Country:US
Practice Address - Phone:970-490-4209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37327207RI0200X, 207R00000X, 2083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO78088577Medicaid
COP00162672OtherMEDICARE RR
NE10025181600Medicaid
WY120663000Medicaid
COP00162672OtherMEDICARE RR