Provider Demographics
NPI:1104965383
Name:LIAO, JIMMY K (MD)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:K
Last Name:LIAO
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 1:2557 PEARBLOSSOM ST
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-4407
Mailing Address - Country:US
Mailing Address - Phone:310-403-2677
Mailing Address - Fax:
Practice Address - Street 1:2557 PEARBLOSSOM ST
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-4407
Practice Address - Country:US
Practice Address - Phone:310-403-2677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66300207R00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No282N00000XHospitalsGeneral Acute Care Hospital