Basic Information
| Provider Information | |||||||||
| NPI: | 1003301144 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TODUA | ||||||||
| FirstName: | IRAKLI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5301 FARAON ST STE 120 | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645063512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162711066 | ||||||||
| FaxNumber: | 8162716786 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 HEARTLAND RD STE 3800 | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645066201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166714800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2018 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 2021023742 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.