Basic Information
| Provider Information | |||||||||
| NPI: | 1770630857 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VITSKY | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | HOWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 144333 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328144333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074229831 | ||||||||
| FaxNumber: | 4072061767 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 SHIRCLIFF WAY | ||||||||
| Address2: | DEPT OF PATHOLOGY | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043083802 | ||||||||
| FaxNumber: | 9043082970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 11/16/2009 | ||||||||
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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 | 207ZP0102X | ME18637 | FL | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZD0900X | ME18637 | FL | N | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZB0001X | ME18637 | FL | N | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine |
ID Information
| ID | Type | State | Issuer | Description | 035157100 | 05 | FL | MEDICAID |