Provider Demographics
NPI:1306878731
Name:TKESHELASHVILI, DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:TKESHELASHVILI
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 1:60 WESTWOOD AVE
Mailing Address - Street 2:SUITE320
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2460
Mailing Address - Country:US
Mailing Address - Phone:203-756-8995
Mailing Address - Fax:203-756-4041
Practice Address - Street 1:60 WESTWOOD AVE
Practice Address - Street 2:SUITE320
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2460
Practice Address - Country:US
Practice Address - Phone:203-756-8995
Practice Address - Fax:203-756-4041
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0361132084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1361138Medicaid
CT1361138Medicaid