Provider Demographics
NPI:1386613743
Name:LISS, JONATHAN LEONARD (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:LEONARD
Last Name:LISS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0160
Mailing Address - Country:US
Mailing Address - Phone:706-327-4000
Mailing Address - Fax:706-324-2557
Practice Address - Street 1:7196 N LAKE DR
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-1693
Practice Address - Country:US
Practice Address - Phone:706-327-4000
Practice Address - Fax:706-324-2557
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0398502084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00651934BMedicaid
GAGRP6221Medicare ID - Type Unspecified
GA00651934BMedicaid