Provider Demographics
NPI:1346407129
Name:TAKTAKISHVILI, OTAR MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:OTAR
Middle Name:MICHAEL
Last Name:TAKTAKISHVILI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:259 1ST ST
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3957
Mailing Address - Country:US
Mailing Address - Phone:516-663-2727
Mailing Address - Fax:516-663-2727
Practice Address - Street 1:259 1ST ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3957
Practice Address - Country:US
Practice Address - Phone:516-663-2727
Practice Address - Fax:516-663-2727
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT054323207P00000X
NY260699207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine