Healthcare Provider Details

I. General information

NPI: 1114125309
Provider Name (Legal Business Name): NIKOLAY MINDADZE, MD,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

774 CHRISTIANA RD
NEWARK DE
19713-4236
US

IV. Provider business mailing address

774 CHRISTIANA RD
NEWARK DE
19713-4236
US

V. Phone/Fax

Practice location:
  • Phone: 302-366-7671
  • Fax: 302-366-7549
Mailing address:
  • Phone: 302-366-7671
  • Fax: 302-366-7549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberC10008143
License Number StateDE

VIII. Authorized Official

Name: DR. NIKOLAY MINDADZE
Title or Position: OWNER
Credential: PHYSICIAN
Phone: 302-366-7671