Basic Information
| Provider Information | |||||||||
| NPI: | 1386959179 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAVID KAVTARADZE MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1008 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | CORDELE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310153761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292714608 | ||||||||
| FaxNumber: | 2292714609 | ||||||||
| Practice Location | |||||||||
| Address1: | 902 N 7TH ST # 100 | ||||||||
| Address2: | |||||||||
| City: | CORDELE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310153234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292762286 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2010 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | KAVTARADZE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2292714608 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 051148 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | 051148 | GA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000976214D | 05 | GA | MEDICAID |