Basic Information
| Provider Information | |||||||||
| NPI: | 1043278864 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOKICHASHVILI | ||||||||
| FirstName: | MAIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 600 GRESHAM DR FL 5 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235071904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573883198 | ||||||||
| FaxNumber: | 7573884242 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 GRESHAM DR FL 5 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235071904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573883198 | ||||||||
| FaxNumber: | 7573884242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 01/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | NE23395 | NE | N | Other Service Providers | Specialist | 208M00000X | 0101243380 | VA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 0101243380 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | NE23395 | 05 | NE | MEDICAID | P00234141 | 01 | NE | RAILROAD MEDICARE NUMBER | OTHER | 247598 | 01 | NE | MIDLANDS CHOICE PROVIDER | OTHER | 30375 | 01 | NE | BC BS IDENTIFICATION NUMB | OTHER |