Provider Demographics
NPI:1679584494
Name:LISS, JAY LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:LAWRENCE
Last Name:LISS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:8711 WATSON RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-5100
Mailing Address - Country:US
Mailing Address - Phone:314-961-9871
Mailing Address - Fax:314-961-9877
Practice Address - Street 1:8711 WATSON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-5100
Practice Address - Country:US
Practice Address - Phone:314-961-9871
Practice Address - Fax:314-961-9877
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2008-04-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO307592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200765907Medicaid
MO916745640OtherMEDICARE PTAN
MO200765907Medicaid