Provider Demographics
NPI:1659638708
Name:LIFF, JEREMY MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:MICHAEL
Last Name:LIFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 WESTMINSTER AVE
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-3913
Mailing Address - Country:US
Mailing Address - Phone:201-387-1957
Mailing Address - Fax:
Practice Address - Street 1:2200 NORTHERN BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:GREENVALE
Practice Address - State:NY
Practice Address - Zip Code:11548
Practice Address - Country:US
Practice Address - Phone:718-630-1270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-13
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY259539207R00000X
NJ25MA09113800207R00000X, 2084V0102X
NY259539-12084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ245975M60Medicare PIN