Provider Demographics
NPI:1669605747
Name:LIU, BO (MD)
Entity type:Individual
Prefix:DR
First Name:BO
Middle Name:
Last Name:LIU
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 1:8608 UTICA AVE STE 218
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4879
Mailing Address - Country:US
Mailing Address - Phone:626-569-0088
Mailing Address - Fax:866-443-7567
Practice Address - Street 1:8608 UTICA AVE STE 218
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4879
Practice Address - Country:US
Practice Address - Phone:626-569-0088
Practice Address - Fax:866-443-7567
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-24
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA109174208600000X, 208D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01545809OtherRAILROAD MEDICARE
CAP01545809OtherRAILROAD MEDICARE
CACA146002Medicare PIN
CACA146001Medicare PIN
VA1669605747Medicaid