Provider Demographics
NPI:1053359067
Name:TIQUE, LILIANA (MD)
Entity type:Individual
Prefix:DR
First Name:LILIANA
Middle Name:
Last Name:TIQUE
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:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2701 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:ISLIP TERRACE
Practice Address - State:NY
Practice Address - Zip Code:11752-2612
Practice Address - Country:US
Practice Address - Phone:631-581-9330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219602207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02379995Medicaid
NY7740538OtherAETNA
NY508Y31OtherEMPIRE BC.BS
NY557Y01Medicare ID - Type Unspecified
NY508Y31OtherEMPIRE BC.BS