Provider Demographics
NPI:1992867600
Name:LIAW, JENNY J (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNY
Middle Name:J
Last Name:LIAW
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 1:21017 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3239
Mailing Address - Country:US
Mailing Address - Phone:718-224-6528
Mailing Address - Fax:718-224-8964
Practice Address - Street 1:21017 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3239
Practice Address - Country:US
Practice Address - Phone:718-224-6528
Practice Address - Fax:718-224-8964
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY182058174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01435372Medicaid
NYF54204Medicare UPIN
NY01435372Medicaid