Provider Demographics
NPI:1396739157
Name:UNAEZE, VITALIS (MD)
Entity type:Individual
Prefix:DR
First Name:VITALIS
Middle Name:
Last Name:UNAEZE
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 1:1839 CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-8900
Mailing Address - Country:US
Mailing Address - Phone:727-322-1054
Mailing Address - Fax:727-322-6184
Practice Address - Street 1:1839 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-8900
Practice Address - Country:US
Practice Address - Phone:727-322-1054
Practice Address - Fax:727-322-6184
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0075910207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254879800Medicaid
FL110216450OtherRAILROAD MEDICARE
FL110216450OtherRR MEDICARE
FL44365OtherBC FL
G84483Medicare UPIN
FL110216450OtherRAILROAD MEDICARE
FL110216450OtherRR MEDICARE