Healthcare Provider Details

I. General information

NPI: 1639103039
Provider Name (Legal Business Name): JONATHAN JAY LIU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 06/23/2022
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 VILLAGE HARBOR DR
LAKE WYLIE SC
29710-9092
US

IV. Provider business mailing address

PO BOX 744786
ATLANTA GA
30374-4786
US

V. Phone/Fax

Practice location:
  • Phone: 803-631-2858
  • Fax: 803-631-2862
Mailing address:
  • Phone: 704-834-2450
  • Fax: 704-671-5331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2016-02298
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28083
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: