Provider Demographics
NPI:1760469084
Name:NAZAROV, VITALY (MD)
Entity Type:Individual
Prefix:DR
First Name:VITALY
Middle Name:
Last Name:NAZAROV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:130 W RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3837
Practice Address - Country:US
Practice Address - Phone:423-224-3628
Practice Address - Fax:423-230-8502
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40147208M00000X
VA0101254975208M00000X
MO2017038349207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4122077OtherBCBST
TNTN0119OtherJOHN DEERE HEATLHCARE
TN3334533Medicaid
TN3334533Medicare PIN
VAVVK789B288Medicare PIN
TN4122077OtherBCBST
TN103I116899Medicare PIN