Healthcare Provider Details

I. General information

NPI: 1699088625
Provider Name (Legal Business Name): NICKOLOZ TCHANKOSHVILI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2010
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 E MAIN ST
LEESBURG FL
34748-5399
US

IV. Provider business mailing address

PO BOX 44008
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 352-728-3898
  • Fax: 352-728-6240
Mailing address:
  • Phone: 904-244-3660
  • Fax: 904-244-3425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME120378
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: