Healthcare Provider Details

I. General information

NPI: 1083898167
Provider Name (Legal Business Name): TEIMURAZ URUSHADZE RDCS.,RVT.,ARDMS(ABD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 12/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6210 WILSHIRE BLVD STE 205
LOS ANGELES CA
90048-5105
US

IV. Provider business mailing address

6210 WILSHIRE BLVD STE 205
LOS ANGELES CA
90048-5105
US

V. Phone/Fax

Practice location:
  • Phone: 310-770-9528
  • Fax:
Mailing address:
  • Phone: 310-770-9528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License Number106048
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number106048
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number106048
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: