Basic Information
Provider Information | |||||||||
NPI: | 1629001300 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LIEU | ||||||||
FirstName: | STEVEN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | POB 4131 | ||||||||
Address2: |   | ||||||||
City: | YALESVILLE | ||||||||
State: | CT | ||||||||
PostalCode: | 06492 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2032841340 | ||||||||
FaxNumber: | 2032654557 | ||||||||
Practice Location | |||||||||
Address1: | 435 LEWIS AVE | ||||||||
Address2: | MIDSTATE MEDICAL CENTER | ||||||||
City: | MERIDEN | ||||||||
State: | CT | ||||||||
PostalCode: | 06451 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2032841340 | ||||||||
FaxNumber: | 2032654557 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/08/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
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 | 207R00000X | 040773 | CT | X |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 040773 | CT | X |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 040773 | 01 | CT | CONNECTICARE | OTHER | 010040773CT01 | 01 | CT | BC | OTHER | 2V4960 | 01 | CT | HEALTHNET | OTHER | P00270222 | 01 |   | RRMC | OTHER |