Provider Demographics
NPI:1235392937
Name:GURGENASHVILI, KHATUNA (MD)
Entity Type:Individual
Prefix:
First Name:KHATUNA
Middle Name:
Last Name:GURGENASHVILI
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 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:301-797-9240
Mailing Address - Fax:301-797-0008
Practice Address - Street 1:22 ST PAUL DR
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-1036
Practice Address - Country:US
Practice Address - Phone:301-797-9240
Practice Address - Fax:301-797-0008
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00702492084N0400X
PAMD4391122084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP00945562OtherMEDICARE RR MD
MDW2660029OtherBCBS REGIONAL CAREFIRST W266
PA2544895OtherBCBS FREEDOM BLUE PPO
MD2544895OtherHIGHMARK BCBS MARYLAND POS
PAP00945563OtherMEDICARE RR PA
MD445117100Medicaid
MD972589OtherBCBS LOCAL CAREFIRST KG85
PA103326162Medicaid
PA2544895OtherHIGHMARK BCBS PENNSYLVANIA POS
PA201170M0TMedicare PIN