Healthcare Provider Details

I. General information

NPI: 1780051490
Provider Name (Legal Business Name): IRAKLY PATARAIA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5762 SW 60TH AVE
OCALA FL
34474-5677
US

IV. Provider business mailing address

4646 N MARINE DR
CHICAGO IL
60640-5759
US

V. Phone/Fax

Practice location:
  • Phone: 516-792-0070
  • Fax:
Mailing address:
  • Phone: 773-878-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number135001129
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO4577
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: