Basic Information
| Provider Information | |||||||||
| NPI: | 1942769906 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIU | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | KING | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6431 FANNIN STREET | ||||||||
| Address2: | SUITE MSB 5.196 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135006223 | ||||||||
| FaxNumber: | 7135006270 | ||||||||
| Practice Location | |||||||||
| Address1: | 4445 MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925014135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517883000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2019 | ||||||||
| LastUpdateDate: | 04/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 390200000X | CA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 95500695D75264 | 05 | CA | MEDICAID |