Provider Demographics
NPI:1518988021
Name:TETROKALASHVILI, DAVID (DPM)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:TETROKALASHVILI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2146 BEVERLEY RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-5406
Mailing Address - Country:US
Mailing Address - Phone:718-210-3296
Mailing Address - Fax:877-868-8633
Practice Address - Street 1:2146 BEVERLEY RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-5406
Practice Address - Country:US
Practice Address - Phone:718-210-3296
Practice Address - Fax:877-868-8633
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006091213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02519726Medicaid
NY02838700Medicaid
NYPJ9751Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER #
NYPQW201Medicare ID - Type UnspecifiedGROUP PROVIDER #
NY02838700Medicaid
NY1396762290Medicare PIN