Provider Demographics
NPI:1265657969
Name:EUGENE VITVITSKY MD
Entity Type:Organization
Organization Name:EUGENE VITVITSKY MD
Other - Org Name:HAVASU VEIN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:VITVITSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-855-4411
Mailing Address - Street 1:1845 MCCOLLOCH BLVD
Mailing Address - Street 2:SUITE A-2
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403
Mailing Address - Country:US
Mailing Address - Phone:928-855-4411
Mailing Address - Fax:928-855-4418
Practice Address - Street 1:2046 BURKE LANE
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86406
Practice Address - Country:US
Practice Address - Phone:928-855-4411
Practice Address - Fax:928-855-4418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ351422086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0440881OtherBLUE CROSS OF ARIZONA
AZG54818Medicare UPIN