Healthcare Provider Details

I. General information

NPI: 1952466518
Provider Name (Legal Business Name): RAMAZI OTAROVICH DATIASHVILI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 08/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 BERGEN ST DOC 7200
NEWARK NJ
07103-2425
US

IV. Provider business mailing address

30 BERGEN ST ADMC 12 1205
NEWARK NJ
07107-3000
US

V. Phone/Fax

Practice location:
  • Phone: 973-972-1129
  • Fax: 973-972-2407
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number25MA06921300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: