Provider Demographics
NPI:1720253503
Name:O'CONNELL, TINATIN KHIZANISHVILI (MD)
Entity type:Individual
Prefix:DR
First Name:TINATIN
Middle Name:KHIZANISHVILI
Last Name:O'CONNELL
Suffix:
Gender:
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:ONE GI CREDENTIALING DEPARTMENT
Mailing Address - Street 2:PO BOX 381468
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-1468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8640 SUDLEY RD STE 201
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4404
Practice Address - Country:US
Practice Address - Phone:703-368-6819
Practice Address - Fax:703-330-2923
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101251722207RG0100X, 207RG0100X
TNMD0000044983207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine