Provider Demographics
NPI:1871483594
Name:GVANTSELADZE, BEKA
Entity type:Individual
Prefix:
First Name:BEKA
Middle Name:
Last Name:GVANTSELADZE
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 1:2107 67TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-4731
Mailing Address - Country:US
Mailing Address - Phone:929-781-7474
Mailing Address - Fax:
Practice Address - Street 1:2107 67TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-4731
Practice Address - Country:US
Practice Address - Phone:929-781-7474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-04
Last Update Date:2025-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies