Provider Demographics
NPI:1376797894
Name:DAVITACHVILI, EKA (DPM)
Entity Type:Individual
Prefix:DR
First Name:EKA
Middle Name:
Last Name:DAVITACHVILI
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07432-1521
Mailing Address - Country:US
Mailing Address - Phone:917-399-0361
Mailing Address - Fax:
Practice Address - Street 1:1705 E 17TH ST LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-2645
Practice Address - Country:US
Practice Address - Phone:917-399-0361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-11
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006252213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery