=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376797894
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EKA DAVITACHVILI DPM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2008
-----------------------------------------------------
Last Update Date | 11/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1705 E 17TH ST LOWR LEVEL
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11229-2645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-399-0361
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 71 ORCHARD ST
-----------------------------------------------------
City | MIDLAND PARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07432-1521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-399-0361
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | N006252
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------