Provider Demographics
NPI:1457461865
Name:UNITED MEDICAL DIAGNOSTIC SERVICES P.C.
Entity Type:Organization
Organization Name:UNITED MEDICAL DIAGNOSTIC SERVICES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:TEYMURAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:DATIKASHVILI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-791-5750
Mailing Address - Street 1:1021 FORDHAM LN
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-1013
Mailing Address - Country:US
Mailing Address - Phone:516-791-5750
Mailing Address - Fax:
Practice Address - Street 1:1021 FORDHAM LN
Practice Address - Street 2:
Practice Address - City:WOODMERE
Practice Address - State:NY
Practice Address - Zip Code:11598-1013
Practice Address - Country:US
Practice Address - Phone:516-791-5750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211676208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEN 342OtherMEDICARE ID CODE