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General NPI Number Information
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NPI Number | 1245866862
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Entity Type | Individual
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Provider Name | ANZOR MODZGVRESCHVILI RD
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Gender | Male
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Dates
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Enumeration Date | 03/15/2020
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Last Update Date | 09/20/2022
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Provider Practice Location Address
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Address Line | 15750 JOY RD
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City | DETROIT
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State | MI
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Zip | 48228-2196
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Country | US
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Telephone | 313-273-6850
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Fax |
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Provider Business Mailing Address
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Address Line | 6201 GREENLEIGH AVE
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City | MIDDLE RIVER
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State | MD
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Zip | 21220-2004
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133VN1101X
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Taxonomy Name | Gerontological Nutrition Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 133VN1101X
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Taxonomy Name | Gerontological Nutrition Registered Dietitian
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License Number | C05672
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License Number State | MD
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