Provider Demographics
NPI:1043487507
Name:IDOIDZE, NINO (MD)
Entity Type:Individual
Prefix:
First Name:NINO
Middle Name:
Last Name:IDOIDZE
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 1:23350 N PROVIDENCE DR
Mailing Address - Street 2:
Mailing Address - City:KILDEER
Mailing Address - State:IL
Mailing Address - Zip Code:60047-8092
Mailing Address - Country:US
Mailing Address - Phone:603-832-8772
Mailing Address - Fax:
Practice Address - Street 1:80 HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246-3235
Practice Address - Country:US
Practice Address - Phone:603-524-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH13824207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine