Provider Demographics
NPI:1568495323
Name:STEPKOVITCH, KHATUNA (MD)
Entity Type:Individual
Prefix:
First Name:KHATUNA
Middle Name:
Last Name:STEPKOVITCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KHATUNA
Other - Middle Name:
Other - Last Name:NATSVLISHVILI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1/2 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:MARCELLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13108
Mailing Address - Country:US
Mailing Address - Phone:315-673-1529
Mailing Address - Fax:315-673-2434
Practice Address - Street 1:1/2 ORANGE STREET
Practice Address - Street 2:DR.STEPKOVITCH'S OFICE
Practice Address - City:MARCELLUS
Practice Address - State:NY
Practice Address - Zip Code:13108
Practice Address - Country:US
Practice Address - Phone:315-673-1529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236662207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA7930Medicare PIN
I40553Medicare UPIN