Provider Demographics
NPI:1770721235
Name:CARSON D LIU, MD, MEDCORP
Entity type:Organization
Organization Name:CARSON D LIU, MD, MEDCORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CARSON
Authorized Official - Middle Name:
Authorized Official - Last Name:LIU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-208-0474
Mailing Address - Street 1:PO BOX 51385
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-5685
Mailing Address - Country:US
Mailing Address - Phone:310-208-0474
Mailing Address - Fax:310-208-0374
Practice Address - Street 1:10921 WILSHIRE BLVD STE 1111
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-4005
Practice Address - Country:US
Practice Address - Phone:310-208-0474
Practice Address - Fax:310-208-0374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75372208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG68616Medicare UPIN