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1174529085

NPI Code Detail

MEDICARE: DR. KONSTANTIN DZAMASHVILI MD

MEDICARE: DR. KONSTANTIN DZAMASHVILI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	036093821	IL
2	2084V0102X	Vascular Neurology Physician	036093821	IL
3	2084N0400X	Neurology Physician	ME126918	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	206147046	OTHER		MEDICARE PTAN (INDIVIDUAL)
2	CA4748	OTHER		MEDICARE RAILROAD (GROUP)
3	206147	OTHER		MEDICARE PTAN (GROUP)
6	P00904562	OTHER		MEDICARE RAILROAD (PROVIDER)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	036093821	OTHER	IL	STATE LICENSE
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174529085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KONSTANTIN DZAMASHVILI MD

Provider Business Mailing Address
First Line	:	12670 WHITEHALL DR
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-3619
Country	:	US
Telephone Number	:	239-936-3554
Fax Number	:	239-936-8993

Provider Business Practice Location Address
First Line	:	12670 WHITEHALL DR
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-3619
Country	:	US
Telephone Number	:	239-936-3554
Fax Number	:	239-936-8993

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	11/18/2016

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Directions to “ DR. KONSTANTIN DZAMASHVILI MD” Practice Location

Language	Start Address	Practice Location

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