Provider Demographics
NPI:1043838501
Name:ISAKADZE, MARINE (MD)
Entity type:Individual
Prefix:
First Name:MARINE
Middle Name:
Last Name:ISAKADZE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 HOUMA BLVD APT 701
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-6523
Mailing Address - Country:US
Mailing Address - Phone:404-910-9661
Mailing Address - Fax:
Practice Address - Street 1:2308 HOUMA BLVD APT 701
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-6523
Practice Address - Country:US
Practice Address - Phone:404-910-9661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2531166Medicaid