Provider Demographics
NPI:1114284734
Name:BEREKASHVILI, KETEVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KETEVAN
Middle Name:
Last Name:BEREKASHVILI
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 1:211 61 STREET
Mailing Address - Street 2:APT 1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220
Mailing Address - Country:US
Mailing Address - Phone:718-630-1270
Mailing Address - Fax:201-387-1036
Practice Address - Street 1:211 61ST ST APT 1
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3782
Practice Address - Country:US
Practice Address - Phone:718-630-1270
Practice Address - Fax:201-387-1036
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2867502085R0204X, 2084N0400X, 2084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology