MEDICARE: DR. NONNA DATIASHVILI 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	207R00000X	Internal Medicine Physician	199877	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326032673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NONNA DATIASHVILI MD

Provider Business Mailing Address
First Line	:	227 KOCH BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10312-5416
Country	:	US
Telephone Number	:	718-605-7000
Fax Number	:	718-608-1066

Provider Business Practice Location Address
First Line	:	227 KOCH BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10312-5416
Country	:	US
Telephone Number	:	718-605-7000
Fax Number	:	718-608-1066

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

Provider Enumeration Date	:	09/01/2005
Last Update Date	:	11/17/2010

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