Healthcare Provider Details

I. General information

NPI: 1629390315
Provider Name (Legal Business Name): INNA ELIKASHVILI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2010
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 1ST AVE
NEW YORK NY
10016-6402
US

IV. Provider business mailing address

300 WINSTON DR APT #1002
CLIFFSIDE PARK NJ
07010-3236
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-5550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number256223
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: