Basic Information
| Provider Information | |||||||||
| NPI: | 1396739157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UNAEZE | ||||||||
| FirstName: | VITALIS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1839 CENTRAL AVENUE | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337138900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273221054 | ||||||||
| FaxNumber: | 7273226184 | ||||||||
| Practice Location | |||||||||
| Address1: | 1839 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337138900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273221054 | ||||||||
| FaxNumber: | 7273226184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 03/08/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME0075910 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 254879800 | 05 | FL | MEDICAID | 110216450 | 01 | FL | RAILROAD MEDICARE | OTHER | 110216450 | 01 | FL | RR MEDICARE | OTHER | 44365 | 01 | FL | BC FL | OTHER |