Provider Demographics
NPI:1073609715
Name:LIU-WU, JEANNY M (OD)
Entity type:Individual
Prefix:DR
First Name:JEANNY
Middle Name:M
Last Name:LIU-WU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:3781 FAIRWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125
Mailing Address - Country:US
Mailing Address - Phone:651-735-3477
Mailing Address - Fax:
Practice Address - Street 1:PEARLE VISION
Practice Address - Street 2:3001 WHITE BEAR AVE. NO., SUITE 1050
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109
Practice Address - Country:US
Practice Address - Phone:651-770-3923
Practice Address - Fax:651-770-5316
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN2339152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN12342OtherEYE MED / COLE VISION
MN140725200Medicaid
MN3C313WUOtherBLUE CROSS BLUE SHIELD
MN3C313WUOtherBLUE CROSS BLUE SHIELD
MN410000979Medicare ID - Type UnspecifiedMEDICARE