Individual
DR. KONSTANTIN DZAMASHVILI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
12670 WHITEHALL DR, FORT MYERS, FL 33907-3619
(239) 936-3554
(239) 936-8993
Mailing address
12670 WHITEHALL DR, FORT MYERS, FL 33907-3619
(239) 936-3554
(239) 936-8993
Taxonomy
Speciality
Code
Description
License number
State
2084N0400X
Neurology Physician
036093821
IL
2084N0400X
Neurology Physician
Primary
ME126918
FL
2084V0102X
Vascular Neurology Physician
036093821
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
036093821
STATE LICENSE
IL
05
—
036093821
—
IL
01
—
206147
MEDICARE PTAN (GROUP)
—
01
—
206147046
MEDICARE PTAN (INDIVIDUAL)
—
01
—
CA4748
MEDICARE RAILROAD (GROUP)
—
01
—
P00904562
MEDICARE RAILROAD (PROVIDER)
—
Enumeration date
06/24/2005
Last updated
11/18/2016
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