Provider Demographics
NPI:1801367453
Name:PETRIASHVILI, DMITRI (PTA)
Entity type:Individual
Prefix:
First Name:DMITRI
Middle Name:
Last Name:PETRIASHVILI
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1914 W 5TH ST APT 1F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-2614
Mailing Address - Country:US
Mailing Address - Phone:347-681-5507
Mailing Address - Fax:
Practice Address - Street 1:1914 W 5TH ST APT 1F
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-2614
Practice Address - Country:US
Practice Address - Phone:347-681-5507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011306-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty