Healthcare Provider Details

I. General information

NPI: 1700797917
Provider Name (Legal Business Name): MIKT MEDICAL SUPPLY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 PARK ST STE 241
BROOKLYN NY
11206-4541
US

IV. Provider business mailing address

12 PARK ST STE 241
BROOKLYN NY
11206-4541
US

V. Phone/Fax

Practice location:
  • Phone: 917-230-2768
  • Fax:
Mailing address:
  • Phone: 917-230-2768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MIKHEIL TEVZADZE
Title or Position: CEO & OWNER
Credential:
Phone: 917-230-2768