Provider Demographics
NPI:1174529085
Name:DZAMASHVILI, KONSTANTIN (MD)
Entity type:Individual
Prefix:DR
First Name:KONSTANTIN
Middle Name:
Last Name:DZAMASHVILI
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 1:12670 WHITEHALL DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3619
Mailing Address - Country:US
Mailing Address - Phone:239-936-3554
Mailing Address - Fax:239-936-8993
Practice Address - Street 1:12670 WHITEHALL DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3619
Practice Address - Country:US
Practice Address - Phone:239-936-3554
Practice Address - Fax:239-936-8993
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360938212084N0400X, 2084V0102X
FLME1269182084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
206147046OtherMEDICARE PTAN (INDIVIDUAL)
CA4748OtherMEDICARE RAILROAD (GROUP)
206147OtherMEDICARE PTAN (GROUP)
IL036093821OtherSTATE LICENSE
IL036093821Medicaid
P00904562OtherMEDICARE RAILROAD (PROVIDER)
G74924Medicare UPIN
IL036093821Medicaid
IL036093821Medicaid