Provider Demographics
NPI:1598892804
Name:BREIZER, VITALI (PT)
Entity Type:Individual
Prefix:
First Name:VITALI
Middle Name:
Last Name:BREIZER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3655B OLD COURT RD STE 26
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-3963
Mailing Address - Country:US
Mailing Address - Phone:410-486-0051
Mailing Address - Fax:
Practice Address - Street 1:3655B OLD COURT RD STE 26
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-3963
Practice Address - Country:US
Practice Address - Phone:410-486-0051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18661225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD931QMedicare ID - Type Unspecified