Provider Demographics
NPI:1255872677
Name:LIU, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:LIU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21155 CHIRPING SPARROW RD
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-3765
Mailing Address - Country:US
Mailing Address - Phone:909-263-0425
Mailing Address - Fax:
Practice Address - Street 1:2051 MARENGO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1352
Practice Address - Country:US
Practice Address - Phone:909-263-0425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-17
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1338991390200000X
CAA157221207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program