Provider Demographics
NPI:1093292427
Name:KVANTALIANI, NINO (MD)
Entity Type:Individual
Prefix:
First Name:NINO
Middle Name:
Last Name:KVANTALIANI
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 1:1815 JOHN F KENNEDY BLVD APT 720
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-1705
Mailing Address - Country:US
Mailing Address - Phone:470-558-8888
Mailing Address - Fax:
Practice Address - Street 1:1815 JOHN F KENNEDY BLVD APT 720
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-1705
Practice Address - Country:US
Practice Address - Phone:470-558-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT215375207R00000X
PAMD4772622084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine