Provider Demographics
NPI:1669477485
Name:LIVA, BRADFORD C (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:C
Last Name:LIVA
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 1:119 PROSPECT ST STE 1
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-4451
Mailing Address - Country:US
Mailing Address - Phone:201-444-1185
Mailing Address - Fax:201-444-1403
Practice Address - Street 1:119 PROSPECT ST STE 1
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4451
Practice Address - Country:US
Practice Address - Phone:201-444-1185
Practice Address - Fax:201-444-1403
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA38479207W00000X
NJ38479207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1389301Medicaid
NJ1389301Medicaid
NJ451568BB3Medicare PIN