Provider Demographics
NPI:1487385795
Name:BOSTASHVILI, NIKOLOZI
Entity type:Individual
Prefix:
First Name:NIKOLOZI
Middle Name:
Last Name:BOSTASHVILI
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 1:6 E WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07407-2804
Mailing Address - Country:US
Mailing Address - Phone:201-873-5169
Mailing Address - Fax:
Practice Address - Street 1:234 E 149TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5504
Practice Address - Country:US
Practice Address - Phone:718-579-6840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-19
Last Update Date:2025-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program