Basic Information
| Provider Information | |||||||||
| NPI: | 1154586105 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIAO | ||||||||
| FirstName: | IAN | ||||||||
| MiddleName: | LEONG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1460 G ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974774112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417448613 | ||||||||
| FaxNumber: | 5417448608 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 E 19TH ST | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412967285 | ||||||||
| FaxNumber: | 5412967420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2008 | ||||||||
| LastUpdateDate: | 05/12/2016 | ||||||||
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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 | 207R00000X | 50469 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 003458 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD168027 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500676493 | 05 | OR | MEDICAID | 78703271 | 05 | CO | MEDICAID |