Provider Demographics
NPI:1407134489
Name:MOZAIDZE, TSIALA
Entity Type:Individual
Prefix:
First Name:TSIALA
Middle Name:
Last Name:MOZAIDZE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 YACHT CLUB WAY
Mailing Address - Street 2:#306
Mailing Address - City:HYPOLUXO
Mailing Address - State:FL
Mailing Address - Zip Code:33462
Mailing Address - Country:US
Mailing Address - Phone:570-904-3149
Mailing Address - Fax:877-519-4595
Practice Address - Street 1:5301 S CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33462-1149
Practice Address - Country:US
Practice Address - Phone:561-588-4844
Practice Address - Fax:877-519-4595
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-25
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT199516207R00000X
FLME 120288207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine