Provider Demographics
NPI:1215068697
Name:ELIASHVILI, JOSEPH (MEDICAL DOCTOR)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:
Last Name:ELIASHVILI
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 DITMAS AVENUE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218
Mailing Address - Country:US
Mailing Address - Phone:718-972-3693
Mailing Address - Fax:718-972-4811
Practice Address - Street 1:401 DITMAS AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218
Practice Address - Country:US
Practice Address - Phone:718-972-3693
Practice Address - Fax:718-972-4811
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY142220207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00482577Medicaid
NY00482577Medicaid
B12336Medicare UPIN