Provider Demographics
NPI:1902906142
Name:LISS, MARK R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:LISS
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 1:140 LOCKWOOD AVE
Mailing Address - Street 2:SUITE 318
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10801-4915
Mailing Address - Country:US
Mailing Address - Phone:914-633-0888
Mailing Address - Fax:914-633-0951
Practice Address - Street 1:140 LOCKWOOD AVE
Practice Address - Street 2:SUITE 318
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-4915
Practice Address - Country:US
Practice Address - Phone:914-633-0888
Practice Address - Fax:914-633-0951
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY137170174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY70A833Medicare ID - Type Unspecified
NYC11967Medicare UPIN