Provider Demographics
NPI:1508353517
Name:KIRVALIDZE, MARIAM M (DO)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:M
Last Name:KIRVALIDZE
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:1033 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-1502
Mailing Address - Country:US
Mailing Address - Phone:516-473-0782
Mailing Address - Fax:516-253-2150
Practice Address - Street 1:181 N BELLE MEAD RD STE 2
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3495
Practice Address - Country:US
Practice Address - Phone:631-444-5858
Practice Address - Fax:631-444-1899
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-16
Last Update Date:2022-09-25
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Provider Licenses
StateLicense IDTaxonomies
NY310737207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine