Individual
DR. TEYMURAZ DATIKASHVILI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
10825 63RD AVE, 1ST FL, FOREST HILLS, NY 11375-1342
(718) 896-2011
Mailing address
1021 FORDHAM LN, WOODMERE, NY 11598-1013
Taxonomy
Speciality
Code
Description
License number
State
208100000X
Physical Medicine & Rehabilitation Physician
Primary
211676
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
G100007358
MEDICARE GROUP PTAN
NY
Enumeration date
05/16/2006
Last updated
05/19/2016
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