Healthcare Provider Details

I. General information

NPI: 1407933450
Provider Name (Legal Business Name): DEBORAH J LIEF-DIENSTAG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 BROADWAY
LAWRENCE NY
11559-1805
US

IV. Provider business mailing address

379 BROADWAY
LAWRENCE NY
11559-1805
US

V. Phone/Fax

Practice location:
  • Phone: 516-569-4768
  • Fax: 516-569-4180
Mailing address:
  • Phone: 516-569-4768
  • Fax: 516-569-4180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number149083
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: