Provider Demographics
NPI:1215956206
Name:LIU, TEDDY TAT-TAK (MD)
Entity type:Individual
Prefix:DR
First Name:TEDDY
Middle Name:TAT-TAK
Last Name:LIU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:24 HAMPSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023-2219
Mailing Address - Country:US
Mailing Address - Phone:516-487-3901
Mailing Address - Fax:516-487-3901
Practice Address - Street 1:133-47 SANFORD AVE
Practice Address - Street 2:STE C1EN
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5800
Practice Address - Country:US
Practice Address - Phone:718-888-9220
Practice Address - Fax:718-539-9344
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206131208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01863065Medicaid
NY01863065Medicaid