Healthcare Provider Details

I. General information

NPI: 1720016140
Provider Name (Legal Business Name): JONATHAN ERIC LIEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 09/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 OAK PARK BLVD
PISMO BEACH CA
93449-3292
US

IV. Provider business mailing address

877 OAK PARK BLVD
PISMO BEACH CA
93449-3292
US

V. Phone/Fax

Practice location:
  • Phone: 805-474-8450
  • Fax: 805-474-8454
Mailing address:
  • Phone: 805-474-8450
  • Fax: 805-474-8454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA92188
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: