Provider Demographics
NPI:1891721171
Name:LIAU, CHIANGYUAN CHUCK (MD)
Entity Type:Individual
Prefix:
First Name:CHIANGYUAN
Middle Name:CHUCK
Last Name:LIAU
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:PO BOX 18704
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92623-8704
Mailing Address - Country:US
Mailing Address - Phone:909-510-7678
Mailing Address - Fax:949-333-2178
Practice Address - Street 1:875 N BREA BLVD
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-2606
Practice Address - Country:US
Practice Address - Phone:714-529-6842
Practice Address - Fax:714-256-1728
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31031207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A310310Medicaid
CAA31031AMedicare PIN
CA00A310310Medicaid
CAE86377Medicare UPIN