Provider Demographics
NPI:1376544932
Name:DATUNASHVILI, ANN R (MD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:R
Last Name:DATUNASHVILI
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 1:874 HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1106
Mailing Address - Country:US
Mailing Address - Phone:203-688-8200
Mailing Address - Fax:203-688-8204
Practice Address - Street 1:874 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1106
Practice Address - Country:US
Practice Address - Phone:203-688-8200
Practice Address - Fax:203-688-8204
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039938207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT061561581OtherHEALTH CT
CTP3307906OtherOXFORD
CT2V6380OtherHEALTH NET
CT367593OtherWELLCARE OF CT
CTP00132026OtherRAIL ROAD MEDICARE
CT039938OtherCONNECTICARE
CT010039938CT01OtherANTHEM BC/BS
CT061561581OtherUNITED HEALTHCARE
CT3621604OtherAETNA
CT061561581OtherCIGNA
CT001399387Medicaid
CT010039938CT01OtherANTHEM BC/BS
CTD400015692Medicare PIN