Provider Demographics
NPI:1952716573
Name:LIEU, SANDY (MD)
Entity type:Individual
Prefix:DR
First Name:SANDY
Middle Name:
Last Name:LIEU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8613 MS HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:ACKERMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39735-8917
Mailing Address - Country:US
Mailing Address - Phone:662-285-4400
Mailing Address - Fax:
Practice Address - Street 1:8613 MS HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:ACKERMAN
Practice Address - State:MS
Practice Address - Zip Code:39735-8917
Practice Address - Country:US
Practice Address - Phone:662-285-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS24038207P00000X, 208M00000X, 207Q00000X
CAA141935207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08506761Medicaid