Basic Information
| Provider Information | |||||||||
| NPI: | 1114997772 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIU | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3591 CRESPI CT | ||||||||
| Address2: | |||||||||
| City: | PLEASANTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945667561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9254632150 | ||||||||
| FaxNumber: | 9254631186 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901B SANTA RITA RD | ||||||||
| Address2: | |||||||||
| City: | PLEASANTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945883462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9254632150 | ||||||||
| FaxNumber: | 9254631186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 7516TPL | CA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | GSD004240 | 05 | CA | MEDICAID |