Provider Demographics
NPI:1154050904
Name:SHOTA GURTCH, M.D., INC. A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SHOTA GURTCH, M.D., INC. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHOTA
Authorized Official - Middle Name:
Authorized Official - Last Name:GURCHUMELIDZE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-997-3161
Mailing Address - Street 1:8875 LA MESA BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-5434
Mailing Address - Country:US
Mailing Address - Phone:619-668-8100
Mailing Address - Fax:619-667-2688
Practice Address - Street 1:8875 LA MESA BLVD STE C
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-5434
Practice Address - Country:US
Practice Address - Phone:619-668-8100
Practice Address - Fax:619-667-2688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-07
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care