Provider Demographics
NPI:1780697854
Name:BREVARD UROLOGY ASSOCIATES PA
Entity type:Organization
Organization Name:BREVARD UROLOGY ASSOCIATES PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:VITAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:321-631-2070
Mailing Address - Street 1:1026 PATHFINDER WAY
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955
Mailing Address - Country:US
Mailing Address - Phone:321-631-2070
Mailing Address - Fax:321-631-6489
Practice Address - Street 1:1026 PATHFINDER WAY
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955
Practice Address - Country:US
Practice Address - Phone:321-631-2070
Practice Address - Fax:321-631-6489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
94834Medicare ID - Type Unspecified