Provider Demographics
NPI:1013911395
Name:LIU, SOPHIE I (DPM)
Entity Type:Individual
Prefix:DR
First Name:SOPHIE
Middle Name:I
Last Name:LIU
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5340 TOSCANA WAY APT 316
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-5660
Mailing Address - Country:US
Mailing Address - Phone:314-565-2773
Mailing Address - Fax:
Practice Address - Street 1:7297 RONSON RD STE H
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-1428
Practice Address - Country:US
Practice Address - Phone:858-278-6603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000758213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO308938208Medicaid
MO6709230001OtherDMERC
MOMA1588Medicare PIN
MO308938208Medicaid