Provider Demographics
NPI:1801532130
Name:MAMUTCHADZE, RUSUDAN (MD)
Entity type:Individual
Prefix:MS
First Name:RUSUDAN
Middle Name:
Last Name:MAMUTCHADZE
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 1:79-01 BROADWAY
Mailing Address - Street 2:A7-34
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373
Mailing Address - Country:US
Mailing Address - Phone:718-334-2156
Mailing Address - Fax:718-334-2862
Practice Address - Street 1:79-01 BROADWAY, QUEENS
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:11373
Practice Address - Country:US
Practice Address - Phone:718-334-2156
Practice Address - Fax:718-334-2862
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2023-05-08
Deactivation Date:2022-12-21
Deactivation Code:
Reactivation Date:2023-05-08
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program