Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 2021023742 | MO |
Y | 111NI0900X | Internist | 2021023742 | MO |
NPI | 1003301144 |
---|---|
Provider Name | Mr. Irakli Todua |
First Address | Brooklyn, NY 11235-7745 |
Second Address | Brooklyn, NY 11235-5012 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/06/2018 |
Last Update Date | 07/09/2021 |