Provider Demographics
NPI:1447354501
Name:LIAO, THERESA (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:LIAO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 LYONS AVE
Mailing Address - Street 2:L-4
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07112-2027
Mailing Address - Country:US
Mailing Address - Phone:973-926-7472
Mailing Address - Fax:973-923-8063
Practice Address - Street 1:201 LYONS AVE
Practice Address - Street 2:L-4
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-2027
Practice Address - Country:US
Practice Address - Phone:973-926-7472
Practice Address - Fax:973-923-8063
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037960207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
7427410001OtherCIGNA
735258OtherCONNECTICARE
010037960CT04OtherANTHEM BCBS
2659952OtherAETNA US HEALTH
236972503OtherUNITED HEALTHCARE
P2575218OtherOXFORD
H03025Medicare UPIN
CT004235736Medicare ID - Type Unspecified
7427410001OtherCIGNA