Provider Demographics
NPI:1720016140
Name:LIEN, JONATHAN ERIC (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ERIC
Last Name:LIEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 OAK PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3292
Mailing Address - Country:US
Mailing Address - Phone:805-474-8450
Mailing Address - Fax:805-474-8454
Practice Address - Street 1:877 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3292
Practice Address - Country:US
Practice Address - Phone:805-474-8450
Practice Address - Fax:805-474-8454
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92188207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A921880Medicaid
CAWA92188BMedicare PIN
CABC902ZMedicare PIN