Provider Demographics
NPI:1013578038
Name:AGLADZE, MARIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIAM
Middle Name:
Last Name:AGLADZE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 FAIRFAX AVE STE 563
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1912
Mailing Address - Country:US
Mailing Address - Phone:757-446-7065
Mailing Address - Fax:
Practice Address - Street 1:550 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101279837207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program