1700882297 NPI number — DR. VLADIMIR KAKITELASHVILI M.D.

Table of content: DR. VLADIMIR KAKITELASHVILI M.D. (NPI 1700882297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700882297 NPI number — DR. VLADIMIR KAKITELASHVILI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KAKITELASHVILI
Provider First Name:
VLADIMIR
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1700882297
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
32 BROADWAY MALL
Provider Second Line Business Mailing Address:
C/O UNIVERSAL HEALTH NETWORK
Provider Business Mailing Address City Name:
HORNELL
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14843-1920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-846-5527
Provider Business Mailing Address Fax Number:
607-324-2369

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 CENTENNIAL ST
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
LA PLATA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20646-5975
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-392-0525
Provider Business Practice Location Address Fax Number:
301-392-0458
Provider Enumeration Date:
06/21/2005

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: 208800000X , with the licence number:  D0057225 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 610737600 . This is a "FED WORKERS COMP - OWCP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1095167 . This is a "AETNA HMO/POS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1552286 . This is a "CIGNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 827840 . This is a "JOHNS HOPKINS GROUP #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 2249341 . This is a "UNITED HC/AMERICHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 85484 . This is a "AMERIGROUP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 7801404 . This is a "AETNA ELECT CHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 510328200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 616119-04 . This is a "CARE FIRST BC/BS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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