Provider Demographics
NPI:1841003589
Name:GVENTSADZE, MAMUKA
Entity type:Individual
Prefix:
First Name:MAMUKA
Middle Name:
Last Name:GVENTSADZE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 PARKWAY RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-5463
Mailing Address - Country:US
Mailing Address - Phone:617-416-4203
Mailing Address - Fax:
Practice Address - Street 1:6 PARKWAY RD
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-5463
Practice Address - Country:US
Practice Address - Phone:617-416-4203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-28
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3017581208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery