Provider Demographics
NPI:1013358654
Name:ABUSERIDZE, VICTOR
Entity Type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:
Last Name:ABUSERIDZE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2145 OCEAN AVE APT A9
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1470
Mailing Address - Country:US
Mailing Address - Phone:347-549-6512
Mailing Address - Fax:
Practice Address - Street 1:2145 OCEAN AVENUE, APT. 9A
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229
Practice Address - Country:US
Practice Address - Phone:347-549-6512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYHHACERTIFICATEA00483374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA00483OtherHHA CERTIFICATE