Provider Demographics
NPI:1720264914
Name:KUTATELADZE, NANA (MD)
Entity Type:Individual
Prefix:
First Name:NANA
Middle Name:
Last Name:KUTATELADZE
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:PO BOX 156
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21922-0156
Mailing Address - Country:US
Mailing Address - Phone:410-398-4679
Mailing Address - Fax:
Practice Address - Street 1:111 CONTINENTAL DR
Practice Address - Street 2:SUITE 406
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-4306
Practice Address - Country:US
Practice Address - Phone:302-984-2577
Practice Address - Fax:302-368-1271
Is Sole Proprietor?:No
Enumeration Date:2008-01-17
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0008503207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine