Provider Demographics
NPI:1225101801
Name:LISS, MERYL JILL (OD)
Entity Type:Individual
Prefix:DR
First Name:MERYL
Middle Name:JILL
Last Name:LISS
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 1:20 A CHESTNUT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MONTVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07645-1802
Mailing Address - Country:US
Mailing Address - Phone:201-391-2011
Mailing Address - Fax:201-391-2016
Practice Address - Street 1:20 A CHESTNUT RIDGE RD
Practice Address - Street 2:
Practice Address - City:MONTVALE
Practice Address - State:NJ
Practice Address - Zip Code:07645
Practice Address - Country:US
Practice Address - Phone:201-391-2011
Practice Address - Fax:201-391-2016
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4815152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T88174Medicare UPIN
NJ0538940001Medicare NSC
NJLI564590Medicare PIN