Provider Demographics
NPI:1023439338
Name:GOLDMAN HUERTAS, LIZA (MD)
Entity type:Individual
Prefix:
First Name:LIZA
Middle Name:
Last Name:GOLDMAN HUERTAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LIZA
Other - Middle Name:
Other - Last Name:GOLDMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:299 WASHINGTON AVE STE LL
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3039
Mailing Address - Country:US
Mailing Address - Phone:203-288-4288
Mailing Address - Fax:855-414-4010
Practice Address - Street 1:299 WASHINGTON AVE STE LL
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3039
Practice Address - Country:US
Practice Address - Phone:203-288-4288
Practice Address - Fax:855-414-1404
Is Sole Proprietor?:No
Enumeration Date:2014-01-05
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT50785207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008049447Medicaid