Basic Information
| Provider Information | |||||||||
| NPI: | 1639103039 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIU | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | JAY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 744786 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303744786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048342450 | ||||||||
| FaxNumber: | 7046715331 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 VILLAGE HARBOR DR | ||||||||
| Address2: | |||||||||
| City: | LAKE WYLIE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297109092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8036312858 | ||||||||
| FaxNumber: | 8036312862 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2016-02298 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 28083 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1639103039 | 05 | NC | MEDICAID | 280831 | 05 | SC | MEDICAID |