Provider Demographics
NPI:1043278864
Name:KOKICHASHVILI, MAIA (MD)
Entity Type:Individual
Prefix:DR
First Name:MAIA
Middle Name:
Last Name:KOKICHASHVILI
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 1:600 GRESHAM DR FL 5
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1904
Mailing Address - Country:US
Mailing Address - Phone:757-388-3198
Mailing Address - Fax:757-388-4242
Practice Address - Street 1:600 GRESHAM DR FL 5
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-3198
Practice Address - Fax:757-388-4242
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NENE23395174400000X
VA0101243380208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NENE23395Medicaid
NEP00234141OtherRAILROAD MEDICARE NUMBER
NE247598OtherMIDLANDS CHOICE PROVIDER
NE30375OtherBC BS IDENTIFICATION NUMB
NEP00234141OtherRAILROAD MEDICARE NUMBER
NE30375OtherBC BS IDENTIFICATION NUMB