Provider Demographics
NPI:1396859476
Name:LIU, CONNIE C (OD)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:C
Last Name:LIU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2248 D ST
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-5403
Mailing Address - Country:US
Mailing Address - Phone:909-593-3519
Mailing Address - Fax:909-593-3521
Practice Address - Street 1:2248 D ST
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-5403
Practice Address - Country:US
Practice Address - Phone:909-593-3519
Practice Address - Fax:909-593-3521
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13043T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1396859476OtherMEDI-CAL
1396859476OtherMEDI-CAL
CABV780ZMedicare PIN