Provider Demographics
NPI:1770576977
Name:VITAZ, TODD W (MD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:W
Last Name:VITAZ
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 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:275 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2531
Practice Address - Country:US
Practice Address - Phone:616-267-7900
Practice Address - Fax:616-267-7901
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301101710207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3637830OtherCIGNA - NNIKY
KY047131OtherSIHO - NNIKY
IN196290EEEEOtherMEDICARE - IN - NNIKY
MI4301101710Medicaid
KY000023035GOtherHUMANA - NNIKY
KY000000604896OtherANTHEM - NNIKY
IN200365220Medicaid
KY3694171000OtherPASSPORT ADVTG - NNIKY
KYP00711479OtherRAILROAD KY MEDICARE - NNIKY
KYP00711479OtherRAILROAD KY MEDICARE - NNIKY
IN200365220Medicaid
KY047131OtherSIHO - NNIKY
KYP00711479OtherRAILROAD KY MEDICARE - NNIKY
G63174Medicare UPIN