Provider Demographics
NPI:1861417842
Name:LIEU, TONY C (OD)
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:C
Last Name:LIEU
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4209 WINDSPRING ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-5930
Mailing Address - Country:US
Mailing Address - Phone:626-222-3608
Mailing Address - Fax:
Practice Address - Street 1:3833 BEDFORD CANYON RD
Practice Address - Street 2:SUITE C101
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92883-0788
Practice Address - Country:US
Practice Address - Phone:951-898-6979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11916T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU95897Medicare UPIN