Healthcare Provider Details

I. General information

NPI: 1255514071
Provider Name (Legal Business Name): PATMAN MZHAVANADZE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 COLISEUM DR STE 445
HAMPTON VA
23666-5906
US

IV. Provider business mailing address

4000 COLISEUM DR STE 445
HAMPTON VA
23666-5906
US

V. Phone/Fax

Practice location:
  • Phone: 757-827-2127
  • Fax: 757-827-2255
Mailing address:
  • Phone: 757-827-2127
  • Fax: 757-827-2255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number0101243441
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101243441
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: