Provider Demographics
NPI:1619912581
Name:VITOVSKY, RODNEY D (PA-C)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:D
Last Name:VITOVSKY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 5TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7304
Mailing Address - Country:US
Mailing Address - Phone:817-250-4280
Mailing Address - Fax:
Practice Address - Street 1:800 5TH AVE STE 500
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7304
Practice Address - Country:US
Practice Address - Phone:817-250-4280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02563363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N8272OtherBLUE CROSS BLUE SHIELD
TX8D2810Medicare PIN
TXS92344Medicare UPIN