Provider Demographics
NPI:1639103039
Name:LIU, JONATHAN JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:JAY
Last Name:LIU
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:PO BOX 744786
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4786
Mailing Address - Country:US
Mailing Address - Phone:704-834-2450
Mailing Address - Fax:704-671-5331
Practice Address - Street 1:1200 VILLAGE HARBOR DR
Practice Address - Street 2:
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710-9092
Practice Address - Country:US
Practice Address - Phone:803-631-2858
Practice Address - Fax:803-631-2862
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-06-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC2016-02298207Q00000X
SC28083207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1639103039Medicaid
SC280831Medicaid