Provider Demographics
NPI:1982628830
Name:LIU, CARSON DAVID (MD,FACS)
Entity Type:Individual
Prefix:DR
First Name:CARSON
Middle Name:DAVID
Last Name:LIU
Suffix:
Gender:M
Credentials:MD,FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 20TH ST.
Mailing Address - Street 2:SUITE 440
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404
Mailing Address - Country:US
Mailing Address - Phone:310-208-0474
Mailing Address - Fax:310-208-0374
Practice Address - Street 1:1301 20TH ST
Practice Address - Street 2:SUITE 440
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-208-0474
Practice Address - Fax:310-208-0374
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75372208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G753720OtherMEDICAL PPIN #
CA00G753720OtherMEDICAL PPIN #
CAWG75372AMedicare PIN