Basic Information
| Provider Information | |||||||||
| NPI: | 1356925770 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUKIANOV | ||||||||
| FirstName: | CYRIL | ||||||||
| MiddleName: | IGOREVICH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3178 ALTAMONT CT | ||||||||
| Address2: | |||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300393612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046972913 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 96 JONATHAN LUCAS ST RM 301 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294258900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437923221 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2021 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.