Provider Demographics
NPI:1255774527
Name:GVALIA, KETEVAN (M D)
Entity type:Individual
Prefix:
First Name:KETEVAN
Middle Name:
Last Name:GVALIA
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:KETEVAN
Other - Middle Name:
Other - Last Name:FRIEDKIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:M D
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-2369
Practice Address - Country:US
Practice Address - Phone:570-703-7351
Practice Address - Fax:570-703-7801
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATMD005308208M00000X
IN01079486A208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist