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General NPI Number Information
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NPI Number | 1326533316
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Entity Type | Individual
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Provider Name | MARIAM TSIKVADZE M.D.
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Gender | Female
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Dates
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Enumeration Date | 06/22/2018
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Last Update Date | 08/06/2024
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Provider Practice Location Address
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Address Line | 3377 RIVERBEND DR
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City | SPRINGFIELD
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State | OR
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Zip | 97477-8803
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Country | US
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Telephone | 541-222-8400
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Fax | 541-222-8401
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Provider Business Mailing Address
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Address Line | 4500 SAN PABLO RD S
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City | JACKSONVILLE
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State | FL
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Zip | 32224-1865
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Country | US
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Telephone | 904-953-2000
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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 | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | MD218074
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | ME154920
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License Number State | FL
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