Provider Demographics
NPI:1073065777
Name:DERDOVA, LIVIA (OD)
Entity Type:Individual
Prefix:
First Name:LIVIA
Middle Name:
Last Name:DERDOVA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 OLD SHORT HILLS RD.
Mailing Address - Street 2:SUITE 430
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052
Mailing Address - Country:US
Mailing Address - Phone:973-325-3300
Mailing Address - Fax:
Practice Address - Street 1:101 OLD SHORT HILLS RD.
Practice Address - Street 2:SUITE 430
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052
Practice Address - Country:US
Practice Address - Phone:973-325-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00670100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist