1427219583 NPI number — DR. ALEXANDRA LUKIANOFF MD

Table of content: DR. ALEXANDRA LUKIANOFF MD (NPI 1427219583)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427219583 NPI number — DR. ALEXANDRA LUKIANOFF MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUKIANOFF
Provider First Name:
ALEXANDRA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427219583
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 848388
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02284-8388
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-533-2903
Provider Business Mailing Address Fax Number:
860-533-2928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 WESTPARK DR STE 240
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRENTWOOD
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37027-5643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-906-8515
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  61098 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 008057126 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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