Provider Demographics
NPI:1316956501
Name:LIAN, GANG GARY (M,D, PHD)
Entity type:Individual
Prefix:DR
First Name:GANG
Middle Name:GARY
Last Name:LIAN
Suffix:
Gender:M
Credentials:M,D, PHD
Other - Prefix:DR
Other - First Name:GARY
Other - Middle Name:GANG
Other - Last Name:LIAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:180 WESTBROOK RD
Mailing Address - Street 2:BUILDING 5
Mailing Address - City:ESSEX
Mailing Address - State:CT
Mailing Address - Zip Code:06426-1517
Mailing Address - Country:US
Mailing Address - Phone:860-767-1034
Mailing Address - Fax:860-767-3434
Practice Address - Street 1:180 WESTBROOK RD
Practice Address - Street 2:BUILDING 5
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1517
Practice Address - Country:US
Practice Address - Phone:860-767-1034
Practice Address - Fax:860-767-3434
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0411372084N0400X, 2084P0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001411371Medicaid
CT001411371Medicaid
CT130000590Medicare ID - Type Unspecified