Provider Demographics
NPI:1831582329
Name:GOFMAN, LIORA (MS)
Entity type:Individual
Prefix:MS
First Name:LIORA
Middle Name:
Last Name:GOFMAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-2704
Mailing Address - Country:US
Mailing Address - Phone:212-683-8905
Mailing Address - Fax:
Practice Address - Street 1:236 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-2704
Practice Address - Country:US
Practice Address - Phone:212-683-8905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYSQ63413TMedicaid