Basic Information
| Provider Information | |||||||||
| NPI: | 1043477441 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIU DUMLAO | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | ONG | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUMLAO | ||||||||
| OtherFirstName: | THERESA | ||||||||
| OtherMiddleName: | LIU | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2940 E. BANNER GATEWAY DR | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852342165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802566444 | ||||||||
| FaxNumber: | 4802564003 | ||||||||
| Practice Location | |||||||||
| Address1: | 2946 E BANNER GATEWAY DR | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852342165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802566444 | ||||||||
| FaxNumber: | 4802564683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2008 | ||||||||
| LastUpdateDate: | 11/15/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0000X | 25912 | AL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RH0003X | P0083 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RX0202X | 25912 | AL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | 32590 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 139243 | 05 | AL | MEDICAID | 04101524 | 05 | MS | MEDICAID | 287754001 (MDACC) | 05 | TX | MEDICAID | 8DC007 | 01 | TX | BCBS (MDACC) | OTHER | 51591744 | 01 | AL | BCBS - 1 INFIRMARY CIRCLE | OTHER |