Provider Demographics
NPI:1861469900
Name:LIESKE, JONATHAN MICHAEL (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:LIESKE
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Gender:M
Credentials:MD, MPH
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Mailing Address - Street 1:100 BREWSTER BLVD
Mailing Address - Street 2:NAVAL HOSPITAL
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28554-2538
Mailing Address - Country:US
Mailing Address - Phone:910-450-4803
Mailing Address - Fax:910-450-4194
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:NAVAL HOSPITAL
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28554-2538
Practice Address - Country:US
Practice Address - Phone:910-450-4159
Practice Address - Fax:910-450-4194
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2023-08-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101102522171000000X, 2083X0100X
VA622562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No171000000XOther Service ProvidersMilitary Health Care Provider
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine