Provider Demographics
NPI:1841224755
Name:LIU, LIDE (MD)
Entity Type:Individual
Prefix:
First Name:LIDE
Middle Name:
Last Name:LIU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 STATE ROUTE 31 STE 111
Mailing Address - Street 2:
Mailing Address - City:FLEMINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08822-4953
Mailing Address - Country:US
Mailing Address - Phone:908-284-9880
Mailing Address - Fax:908-782-4316
Practice Address - Street 1:111 STATE ROUTE 31 STE 111
Practice Address - Street 2:
Practice Address - City:FLEMINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08822-4953
Practice Address - Country:US
Practice Address - Phone:908-284-9880
Practice Address - Fax:908-782-4316
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-114528207Q00000X
NJ25MA10021900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I51930Medicare UPIN