Provider Demographics
NPI:1831517978
Name:VITVITSKIY, BORIS (DO)
Entity type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:VITVITSKIY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:765-751-2600
Mailing Address - Fax:
Practice Address - Street 1:2525 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3421
Practice Address - Country:US
Practice Address - Phone:765-751-5886
Practice Address - Fax:765-751-5889
Is Sole Proprietor?:No
Enumeration Date:2014-04-05
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02005332A208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300013510Medicaid
IN000001173448OtherANTHEM BC/BS