Basic Information
| Provider Information | |||||||||
| NPI: | 1447305107 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINDADZE | ||||||||
| FirstName: | NIKOLAY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HYGEIA DR STE 2300 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132049 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4735 OGLETOWN STANTON ROAD, SUITE 3301 | ||||||||
| Address2: | MEDICAL ARTS PAVILLION 2 | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026234370 | ||||||||
| FaxNumber: | 3026234375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 12/05/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | C1-0008143 | DE | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1447305107 | 05 | DE | MEDICAID | 266108000 | 05 | MD | MEDICAID | 144677500 | 01 | DE | DEPARTMENT OF LABOR | OTHER | 102891261 001 | 05 | PA | MEDICAID |