Provider Demographics
NPI:1124459078
Name:MIKABERIDZE, NINO (MD)
Entity type:Individual
Prefix:
First Name:NINO
Middle Name:
Last Name:MIKABERIDZE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 5TH AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-8855
Mailing Address - Country:US
Mailing Address - Phone:646-580-3538
Mailing Address - Fax:844-841-8382
Practice Address - Street 1:2 5TH AVE STE 7
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8855
Practice Address - Country:US
Practice Address - Phone:646-580-3538
Practice Address - Fax:844-841-8382
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-03
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY275771207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine