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General NPI Number Information
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NPI Number | 1508353517
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Entity Type | Individual
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Provider Name | MARIAM M KIRVALIDZE DO
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Gender | Female
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Dates
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Enumeration Date | 04/16/2018
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Last Update Date | 09/25/2022
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Provider Practice Location Address
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Address Line | 181 N BELLE MEAD RD STE 2
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City | EAST SETAUKET
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State | NY
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Zip | 11733-3495
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Country | US
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Telephone | 631-444-5858
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Fax | 631-444-1899
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Provider Business Mailing Address
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Address Line | 1033 NORTHERN BLVD
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City | ROSLYN
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State | NY
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Zip | 11576-1502
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Country | US
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Telephone | 516-473-0782
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Fax | 516-253-2150
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 310737
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License Number State | NY
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