Provider Demographics
NPI:1982865457
Name:VITKOVITSKY, IRENA VIVIAN (MD)
Entity Type:Individual
Prefix:
First Name:IRENA
Middle Name:VIVIAN
Last Name:VITKOVITSKY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 POWELL ST
Mailing Address - Street 2:STE 900
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1844
Mailing Address - Country:US
Mailing Address - Phone:510-350-2600
Mailing Address - Fax:
Practice Address - Street 1:660 S EUCLID AVE
Practice Address - Street 2:BOX 8072
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1010
Practice Address - Country:US
Practice Address - Phone:314-362-9177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036130034207P00000X
NV18294207P00000X
MO2008015956207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine