Provider Demographics
NPI:1942266580
Name:LIQUETE, MARIA T (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:T
Last Name:LIQUETE
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 1:220 STANDIFORD AVE STE F
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1159
Mailing Address - Country:US
Mailing Address - Phone:812-604-5870
Mailing Address - Fax:209-579-5637
Practice Address - Street 1:1501 CLAUS RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-9711
Practice Address - Country:US
Practice Address - Phone:209-557-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012443572084P0800X
CAC1310742084P0800X
TN394902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3331581Medicaid
TN3331589Medicaid
WI1435-320Medicaid
TN4114432OtherBCBS
VA021431W82Medicare PIN
TN103I263080Medicare PIN