Provider Demographics
NPI:1386959179
Name:DAVID KAVTARADZE MD INC
Entity type:Organization
Organization Name:DAVID KAVTARADZE MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KAVTARADZE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-271-4608
Mailing Address - Street 1:1008 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-3761
Mailing Address - Country:US
Mailing Address - Phone:229-271-4608
Mailing Address - Fax:229-271-4609
Practice Address - Street 1:902 N 7TH ST # 100
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3234
Practice Address - Country:US
Practice Address - Phone:229-276-2286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-17
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051148207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000976214DMedicaid
GA000976214DMedicaid
GAH75357Medicare UPIN
GA6531880001Medicare NSC