Basic Information
Provider Information | |||||||||
NPI: | 1508353517 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KIRVALIDZE | ||||||||
FirstName: | MARIAM | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1033 NORTHERN BLVD | ||||||||
Address2: |   | ||||||||
City: | ROSLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 115761502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5164730782 | ||||||||
FaxNumber: | 5162532150 | ||||||||
Practice Location | |||||||||
Address1: | 181 N BELLE MEAD RD STE 2 | ||||||||
Address2: |   | ||||||||
City: | EAST SETAUKET | ||||||||
State: | NY | ||||||||
PostalCode: | 117333495 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6314445858 | ||||||||
FaxNumber: | 6314441899 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/16/2018 | ||||||||
LastUpdateDate: | 09/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/12/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 310737 | NY | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.