Provider Demographics
NPI:1245231802
Name:LISKOV, TARA (RD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:LISKOV
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 SILVER LN
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-5343
Mailing Address - Country:US
Mailing Address - Phone:203-386-0044
Mailing Address - Fax:203-377-4156
Practice Address - Street 1:999 SILVER LN
Practice Address - Street 2:SUITE 2A
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-5343
Practice Address - Country:US
Practice Address - Phone:203-386-0044
Practice Address - Fax:203-377-4156
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000358133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT710000003Medicare ID - Type Unspecified