Provider Demographics
NPI:1457433252
Name:KHULORDAVA, IRAKLI (MD)
Entity Type:Individual
Prefix:
First Name:IRAKLI
Middle Name:
Last Name:KHULORDAVA
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 1:819 N FANT ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-5717
Mailing Address - Country:US
Mailing Address - Phone:864-261-1800
Mailing Address - Fax:864-261-1856
Practice Address - Street 1:819 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5717
Practice Address - Country:US
Practice Address - Phone:864-261-1800
Practice Address - Fax:864-261-1856
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29322207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC293220Medicaid
SCP00137642OtherRR MEDICARE
SC293220Medicaid
SCH920390281Medicare PIN