Basic Information
| Provider Information | |||||||||
| NPI: | 1003886409 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIU | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4411 MEDICAL DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106145400 | ||||||||
| FaxNumber: | 2106142413 | ||||||||
| Practice Location | |||||||||
| Address1: | 1139 E SONTERRA BLVD STE 520 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782584347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104906000 | ||||||||
| FaxNumber: | 2104904658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | H4988 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 8CM508 | 01 | TX | BCBS | OTHER | 124300806 | 05 | TX | MEDICAID | TXB112504 | 01 | TX | MEDICARE | OTHER | P00898257 | 01 | TX | RAILROAD MEDICARE | OTHER |