Provider Demographics
NPI:1386674752
Name:VON DER LIETH, ERIC ROY
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:ROY
Last Name:VON DER LIETH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07656-1249
Mailing Address - Country:US
Mailing Address - Phone:201-505-1600
Mailing Address - Fax:
Practice Address - Street 1:43 HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07656-1249
Practice Address - Country:US
Practice Address - Phone:201-505-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00496900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ001413Medicare UPIN