Provider Demographics
NPI:1285632059
Name:MIKHELASHVILI, NODARI (MD)
Entity Type:Individual
Prefix:
First Name:NODARI
Middle Name:
Last Name:MIKHELASHVILI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-3703
Mailing Address - Country:US
Mailing Address - Phone:508-679-3131
Mailing Address - Fax:508-679-7146
Practice Address - Street 1:363 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-3703
Practice Address - Country:US
Practice Address - Phone:508-679-3131
Practice Address - Fax:508-679-7146
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA209688207L00000X
NY241064-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0199087Medicaid
H61923Medicare UPIN
MAA34022Medicare ID - Type Unspecified