Provider Demographics
NPI:1528585544
Name:MORTOB, LIOR (PA-C)
Entity Type:Individual
Prefix:
First Name:LIOR
Middle Name:
Last Name:MORTOB
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 E ROUTE 59
Mailing Address - Street 2:# 408
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-2905
Mailing Address - Country:US
Mailing Address - Phone:718-362-1411
Mailing Address - Fax:718-414-1651
Practice Address - Street 1:234 E 85TH ST FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-3135
Practice Address - Country:US
Practice Address - Phone:212-731-3232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020804-1207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology