Healthcare Provider Details

I. General information

NPI: 1164085015
Provider Name (Legal Business Name): JESSICA BISTAFA LIU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5673 PEACHTREE DUNWOODY RD STE 500
ATLANTA GA
30342-2147
US

IV. Provider business mailing address

PO BOX 102632
ATLANTA GA
30368-2632
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-7402
  • Fax:
Mailing address:
  • Phone: 404-778-7402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number100031
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: