Provider Demographics
NPI:1700975976
Name:LIU, DAVID M K I (MD, PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M K I
Last Name:LIU
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5659
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:2201 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7025
Practice Address - Country:US
Practice Address - Phone:530-543-5623
Practice Address - Fax:530-541-5738
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC56003207R00000X, 208000000X
HI13414207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI13414OtherSTATE LICENSE
CAC56003OtherCALIFORNIA STATE LICENSE
CAGX979ZMedicare PIN