Provider Demographics
NPI:1962465427
Name:KAKABADZE, SHALVA V (MD)
Entity Type:Individual
Prefix:
First Name:SHALVA
Middle Name:V
Last Name:KAKABADZE
Suffix:
Gender:M
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:PO BOX 447
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-0447
Mailing Address - Country:US
Mailing Address - Phone:814-653-8222
Mailing Address - Fax:814-653-9305
Practice Address - Street 1:5 N 3RD ST
Practice Address - Street 2:
Practice Address - City:REYNOLDSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15851-0907
Practice Address - Country:US
Practice Address - Phone:814-653-8222
Practice Address - Fax:814-653-9305
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35079515207Q00000X
PAMD442814207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2257776Medicaid
H38087Medicare UPIN
OHKA4051842Medicare PIN