Healthcare Provider Details

I. General information

NPI: 1669462123
Provider Name (Legal Business Name): VITALY BLATNOY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7560 RED BUG LAKE RD STE 1014
OVIEDO FL
32765-6591
US

IV. Provider business mailing address

7560 RED BUG LAKE RD STE 1014
OVIEDO FL
32765-6591
US

V. Phone/Fax

Practice location:
  • Phone: 407-706-1770
  • Fax: 407-706-1777
Mailing address:
  • Phone: 407-706-1770
  • Fax: 407-706-1777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME92940
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License NumberME92940
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: