Provider Demographics
NPI:1679779409
Name:DGEBUADZE, NINO (MD, PHD)
Entity Type:Individual
Prefix:
First Name:NINO
Middle Name:
Last Name:DGEBUADZE
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 FOREST PARK AVE
Mailing Address - Street 2:CAMPUS BOX 8518
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-8518
Mailing Address - Country:US
Mailing Address - Phone:314-454-7757
Mailing Address - Fax:
Practice Address - Street 1:17 WESTERN MARYLAND PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740
Practice Address - Country:US
Practice Address - Phone:301-797-9240
Practice Address - Fax:301-797-4119
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0073349208100000X
MO2007012244208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD97628601OtherBCBS LOCAL CAREFIRST KG85
MD333505400Medicaid
MDW2660030OtherBCBS REGIONAL W266
MDP01024230OtherRR MEDICARE MD
MDW2660030OtherBCBS REGIONAL W266