Provider Demographics
NPI:1225477748
Name:LISS, ERIC ALEXANDER (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:ALEXANDER
Last Name:LISS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:13904 N DALE MABRY HWY STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-2446
Mailing Address - Country:US
Mailing Address - Phone:813-908-2020
Mailing Address - Fax:813-908-2133
Practice Address - Street 1:14543 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-6065
Practice Address - Country:US
Practice Address - Phone:352-596-4030
Practice Address - Fax:813-908-2133
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME132169207W00000X
VA0116026006390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021114900Medicaid
FLPH823OtherPTAN
FLOD205OtherPTAN