Healthcare Provider Details

I. General information

NPI: 1114284734
Provider Name (Legal Business Name): KETEVAN BEREKASHVILI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2012
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 61ST ST APT 1
BROOKLYN NY
11220-3782
US

IV. Provider business mailing address

211 61 STREET APT 1
BROOKLYN NY
11220
US

V. Phone/Fax

Practice location:
  • Phone: 718-630-1270
  • Fax: 201-387-1036
Mailing address:
  • Phone: 718-630-1270
  • Fax: 201-387-1036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number286750
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number286750
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number286750
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: