Basic Information
| Provider Information | |||||||||
| NPI: | 1518161728 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIAO | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 393 E WALNUT ST | ||||||||
| Address2: | PHR GROUP PROVIDER ENROLLMENT UNIT 3RD FL | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911880001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776080044 | ||||||||
| FaxNumber: | 8775140903 | ||||||||
| Practice Location | |||||||||
| Address1: | 242 E GLENARM ST UNIT 5 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911065413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103647431 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | A91141 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | BL9239410 | 01 | CA | DEA | OTHER | A91141 | 01 | CA | CALIFORNIA MEDICAL BOARD | OTHER |