Provider Demographics
NPI:1518733328
Name:KHARSHILADZE, GOCHA
Entity Type:Individual
Prefix:
First Name:GOCHA
Middle Name:
Last Name:KHARSHILADZE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3918 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-3606
Mailing Address - Country:US
Mailing Address - Phone:718-753-5055
Mailing Address - Fax:
Practice Address - Street 1:3918 13TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-3606
Practice Address - Country:US
Practice Address - Phone:718-753-5055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver