Provider Demographics
NPI:1699330506
Name:LIEU, JUNGWOO JAMES (DO)
Entity type:Individual
Prefix:
First Name:JUNGWOO
Middle Name:JAMES
Last Name:LIEU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4828 CYPRESS ST UNIT 214
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-1441
Mailing Address - Country:US
Mailing Address - Phone:443-629-8427
Mailing Address - Fax:
Practice Address - Street 1:4828 CYPRESS ST UNIT 214
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-1441
Practice Address - Country:US
Practice Address - Phone:443-629-8427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A21260208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program