Mariam Pestvenidze, M.D.

Primary specialty

Student in an Organized Health Care Education/Training ProgramTaxonomy code 390200000X

License

125.083823 Issued in IL

Practice address

355 Ridge Ave
Evanston, IL 60202-3328

Phone

(847) 316-6228

NPI assigned

Jul 19, 2024

Last updated

Jul 19, 2024By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Doctor of Medicine

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1721347200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1721347200000",
    "number": "1427896679",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "419 RIDGE AVE APT H",
            "city": "EVANSTON",
            "state": "IL",
            "postal_code": "602022852",
            "telephone_number": "224-500-9763"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "355 RIDGE AVE",
            "city": "EVANSTON",
            "state": "IL",
            "postal_code": "602023328",
            "telephone_number": "847-316-6228"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PESTVENIDZE",
        "first_name": "MARIAM",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2024-07-19",
        "last_updated": "2024-07-19",
        "certification_date": "2024-07-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "IL",
            "license": "125.083823",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Dimitri G. Perros, M.D.
• Ryan Perry
• Sara Perry
• Inna S Persina, M.D.
• Elene Pestvenidze
• Peter Werner MD
• Christine V. Petersen, PSY D
• Julia Peterson, APN-CNP
• Kristin Lily Peterson, MD
• Lance R Peterson, M.D.

• Student in an Organized Health Care Education/Training Program in Evanston, IL
• Providers in Evanston, IL by specialty
• Student in an Organized Health Care Education/Training Program in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 19, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.