Provider Demographics
NPI:1184937013
Name:LIAO, THEODORE WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:WILLIAM
Last Name:LIAO
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 1:300 LAFAYETTE AVE SE
Mailing Address - Street 2:SUITE 3400
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 LAFAYETTE AVE SE
Practice Address - Street 2:SUITE 3400
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4650
Practice Address - Country:US
Practice Address - Phone:616-685-6741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301096891207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine