Provider Demographics
NPI:1700267978
Name:NARIDZE, RACHELLE LOU (MD)
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:LOU
Last Name:NARIDZE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5310 HARVEST HILL RD STE 290
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-5826
Mailing Address - Country:US
Mailing Address - Phone:214-420-0650
Mailing Address - Fax:
Practice Address - Street 1:700 SAN GABRIEL VILLAGE BLVD STE 105
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-5594
Practice Address - Country:US
Practice Address - Phone:512-598-8757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-14
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT3833207N00000X
IAR-10357207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026480112Medicaid
IA1700267978Medicaid
NE10025715000Medicaid
NE10026480119Medicaid
NE47068731795Medicaid