Healthcare Provider Details

I. General information

NPI: 1861469900
Provider Name (Legal Business Name): JONATHAN MICHAEL LIESKE MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD NAVAL HOSPITAL
CAMP LEJEUNE NC
28554-2538
US

IV. Provider business mailing address

100 BREWSTER BLVD NAVAL HOSPITAL
CAMP LEJEUNE NC
28554-2538
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-4159
  • Fax: 910-450-4194
Mailing address:
  • Phone: 910-450-4803
  • Fax: 910-450-4194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number0101102522
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number62256
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0101102522
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: