Provider Demographics
NPI:1659702553
Name:BORODIN, VITALY (MD)
Entity Type:Individual
Prefix:DR
First Name:VITALY
Middle Name:
Last Name:BORODIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:VITALII
Other - Middle Name:SERGEEVICH
Other - Last Name:BORODIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3301 BAYSHORE BLVD UNIT 1709
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-8845
Mailing Address - Country:US
Mailing Address - Phone:484-350-7158
Mailing Address - Fax:
Practice Address - Street 1:3301 BAYSHORE BLVD UNIT 1709
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-8845
Practice Address - Country:US
Practice Address - Phone:484-350-7158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-03
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME135873207ZC0500X, 207ZP0102X, 207ZP0102X
PAMT201400207ZP0102X, 207ZP0102X
VA0116028958390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology