Provider Demographics
NPI:1023051117
Name:LIU, JEFFREY TA (MD - LLC)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:TA
Last Name:LIU
Suffix:
Gender:M
Credentials:MD - LLC
Other - Prefix:
Other - First Name:JEFFREY
Other - Middle Name:T
Other - Last Name:LIU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3040 W CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1944
Mailing Address - Country:US
Mailing Address - Phone:702-477-0707
Mailing Address - Fax:888-232-5937
Practice Address - Street 1:3040 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1944
Practice Address - Country:US
Practice Address - Phone:702-477-0707
Practice Address - Fax:888-232-5937
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7490207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2019887Medicaid
NV80-0551016OtherTAX IDENTIFICATION
NVCS7890OtherNEVADA PHARMACY
NVCS7890OtherNEVADA PHARMACY
NV80-0551016OtherTAX IDENTIFICATION
NVBL4602202OtherDEA