Healthcare Provider Details

I. General information

NPI: 1245866862
Provider Name (Legal Business Name): ANZOR MODZGVRESCHVILI RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2020
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15750 JOY RD
DETROIT MI
48228-2196
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 313-273-6850
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1101X
TaxonomyGerontological Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133VN1101X
TaxonomyGerontological Nutrition Registered Dietitian
License NumberC05672
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: