Provider Demographics
NPI:1215225552
Name:BALANCHIVADZE, NINO (MD)
Entity Type:Individual
Prefix:
First Name:NINO
Middle Name:
Last Name:BALANCHIVADZE
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 1:6350 CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4107
Mailing Address - Country:US
Mailing Address - Phone:757-905-5558
Mailing Address - Fax:757-213-5762
Practice Address - Street 1:6251 E VIRGINIA BEACH BLVD STE 200
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-2800
Practice Address - Country:US
Practice Address - Phone:757-466-8683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-20
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36560207R00000X
MI4301117273207R00000X
390200000X
VA0101274592207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program