Provider Demographics
NPI:1528629326
Name:RUDROFF, LIZA G (MED, TVI)
Entity type:Individual
Prefix:MRS
First Name:LIZA
Middle Name:G
Last Name:RUDROFF
Suffix:
Gender:F
Credentials:MED, TVI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 WASHINGTON AVE
Mailing Address - Street 2:LWR
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1905
Mailing Address - Country:US
Mailing Address - Phone:716-777-0870
Mailing Address - Fax:
Practice Address - Street 1:85 WASHINGTON AVE
Practice Address - Street 2:LWR
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1905
Practice Address - Country:US
Practice Address - Phone:716-777-0870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-24
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY477735101174400000X
NY1374401191174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist