Provider Demographics
NPI:1821284449
Name:GURCHUMELIDZE, SHOTA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHOTA
Middle Name:
Last Name:GURCHUMELIDZE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SHOTA
Other - Middle Name:P
Other - Last Name:GURTCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:11848 MIRO CIR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-3323
Mailing Address - Country:US
Mailing Address - Phone:858-997-3161
Mailing Address - Fax:
Practice Address - Street 1:8875 LA MESA BLVD STE C
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-5434
Practice Address - Country:US
Practice Address - Phone:619-668-8100
Practice Address - Fax:619-667-2688
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA-101612207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine