Provider Demographics
NPI:1326032673
Name:DATIASHVILI, NONNA (MD)
Entity Type:Individual
Prefix:DR
First Name:NONNA
Middle Name:
Last Name:DATIASHVILI
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 1:227 KOCH BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-5416
Mailing Address - Country:US
Mailing Address - Phone:718-605-7000
Mailing Address - Fax:718-608-1066
Practice Address - Street 1:227 KOCH BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-5416
Practice Address - Country:US
Practice Address - Phone:718-605-7000
Practice Address - Fax:718-608-1066
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199877207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01584789Medicaid
751171Medicare ID - Type Unspecified
NY01584789Medicaid