Healthcare Provider Details

I. General information

NPI: 1922934546
Provider Name (Legal Business Name): LIZZIE LUCKASHVILI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GRAND STREET HOSPITAL OF CENTRAL CONNECTICUT, OUTPATIENT CLINIC
NEW BRITAIN CT
06052
US

IV. Provider business mailing address

263 FARMINGTON AVENUE GRADUATE MEDICAL EDUCATION OFFICE
FARMINGTON CT
06030-1921
US

V. Phone/Fax

Practice location:
  • Phone: 860-224-5261
  • Fax:
Mailing address:
  • Phone: 860-679-2147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: