Provider Demographics
NPI:1609605526
Name:CLEAR LAKE MEDICAL PC
Entity type:Organization
Organization Name:CLEAR LAKE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHE
Authorized Official - Middle Name:
Authorized Official - Last Name:LIU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-409-2508
Mailing Address - Street 1:93 NEW DORP LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-2324
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:93 NEW DORP LN
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-2324
Practice Address - Country:US
Practice Address - Phone:718-435-1025
Practice Address - Fax:718-435-2670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty