Provider Demographics
NPI:1740515824
Name:PELIKHATYY, VITALIY (OD)
Entity type:Individual
Prefix:DR
First Name:VITALIY
Middle Name:
Last Name:PELIKHATYY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8359 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8304
Mailing Address - Country:US
Mailing Address - Phone:360-721-7293
Mailing Address - Fax:
Practice Address - Street 1:8359 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8304
Practice Address - Country:US
Practice Address - Phone:208-321-0901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-07
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID100541152W00000X
WAOD 60241089152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist