Provider Demographics
NPI:1649403767
Name:SHASHIASHVILI, TAMARA I (DO)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:I
Last Name:SHASHIASHVILI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 KENMORE ST
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-8112
Mailing Address - Country:US
Mailing Address - Phone:516-813-7556
Mailing Address - Fax:
Practice Address - Street 1:12 KENMORE ST
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-8112
Practice Address - Country:US
Practice Address - Phone:516-813-7556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266569207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine