Provider Demographics
NPI:1194907279
Name:SIRBILADZE, ROWELLA LICUP (MD)
Entity type:Individual
Prefix:
First Name:ROWELLA
Middle Name:LICUP
Last Name:SIRBILADZE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ROWELLA
Other - Middle Name:MENDOZA
Other - Last Name:LICUP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9646
Mailing Address - Fax:239-343-9681
Practice Address - Street 1:8960 COLONIAL CENTER DR STE 202
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7810
Practice Address - Country:US
Practice Address - Phone:239-343-9646
Practice Address - Fax:239-343-9681
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME151358207RE0101X
TN46347207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114292600Medicaid