Provider Demographics
NPI:1528120748
Name:LIU, WILSON (MD)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:
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 1:3601 VISTA WAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4559
Mailing Address - Country:US
Mailing Address - Phone:760-529-9503
Mailing Address - Fax:760-630-1252
Practice Address - Street 1:3601 VISTA WAY
Practice Address - Street 2:SUITE 201
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4559
Practice Address - Country:US
Practice Address - Phone:760-529-9503
Practice Address - Fax:760-630-1252
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG72764207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F61843Medicare UPIN