Provider Demographics
NPI:1669458550
Name:GAKHOKIDZE, MAIA (MD)
Entity Type:Individual
Prefix:DR
First Name:MAIA
Middle Name:
Last Name:GAKHOKIDZE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 GRESHAM DR FL 5
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1904
Mailing Address - Country:US
Mailing Address - Phone:757-388-3198
Mailing Address - Fax:757-388-4242
Practice Address - Street 1:600 GRESHAM DR FL 5
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-3198
Practice Address - Fax:757-388-4242
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009036027207R00000X
WA43101207R00000X
VA0101253668208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1669458550Medicaid
WA8383457Medicaid
MOP19000004Medicare PIN
WAI02062Medicare UPIN
WA8801717Medicare ID - Type Unspecified
MOP00821408Medicare PIN