Provider Demographics
NPI:1679102362
Name:TOM, LIYA (MD)
Entity type:Individual
Prefix:
First Name:LIYA
Middle Name:
Last Name:TOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LIYA
Other - Middle Name:
Other - Last Name:TOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4315 HIGHLAND PARK BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-1639
Mailing Address - Country:US
Mailing Address - Phone:863-816-5884
Mailing Address - Fax:863-940-4856
Practice Address - Street 1:1324 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4543
Practice Address - Country:US
Practice Address - Phone:863-816-5884
Practice Address - Fax:863-940-4856
Is Sole Proprietor?:No
Enumeration Date:2020-04-04
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME163614207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program