Provider Demographics
NPI:1588176648
Name:GAMBASHIDZE, GIGA
Entity type:Individual
Prefix:
First Name:GIGA
Middle Name:
Last Name:GAMBASHIDZE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1556 W 8TH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-6503
Mailing Address - Country:US
Mailing Address - Phone:646-379-0072
Mailing Address - Fax:
Practice Address - Street 1:1556 W 8TH ST
Practice Address - Street 2:APT 2
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204
Practice Address - Country:US
Practice Address - Phone:646-379-0072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010829-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty