Provider Demographics
NPI:1104873827
Name:DATESHIDZE, KONSTANTIN (MD)
Entity type:Individual
Prefix:
First Name:KONSTANTIN
Middle Name:
Last Name:DATESHIDZE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 TRENTON RD
Mailing Address - Street 2:
Mailing Address - City:BROWNS MILLS
Mailing Address - State:NJ
Mailing Address - Zip Code:08015-1705
Mailing Address - Country:US
Mailing Address - Phone:609-893-1200
Mailing Address - Fax:609-893-1213
Practice Address - Street 1:200 TRENTON RD
Practice Address - Street 2:
Practice Address - City:BROWNS MILLS
Practice Address - State:NJ
Practice Address - Zip Code:08015-1705
Practice Address - Country:US
Practice Address - Phone:609-893-1200
Practice Address - Fax:609-893-1213
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04546400207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0917907Medicaid
NJE75324Medicare UPIN
NJ488419AA2Medicare ID - Type Unspecified