Provider Demographics
NPI:1356928618
Name:HAGGENJOS, LIZA M (DO)
Entity type:Individual
Prefix:
First Name:LIZA
Middle Name:M
Last Name:HAGGENJOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:103 WHITETAIL DR
Practice Address - Street 2:
Practice Address - City:WALHALLA
Practice Address - State:SC
Practice Address - Zip Code:29691-5837
Practice Address - Country:US
Practice Address - Phone:864-638-3444
Practice Address - Fax:864-638-3445
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC92651207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program