Healthcare Provider Details

I. General information

NPI: 1659702553
Provider Name (Legal Business Name): VITALY BORODIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: VITALII SERGEEVICH BORODIN M.D.

II. Dates (important events)

Enumeration Date: 12/03/2013
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 BAYSHORE BLVD UNIT 1709
TAMPA FL
33629-8845
US

IV. Provider business mailing address

3301 BAYSHORE BLVD UNIT 1709
TAMPA FL
33629-8845
US

V. Phone/Fax

Practice location:
  • Phone: 484-350-7158
  • Fax:
Mailing address:
  • Phone: 484-350-7158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberME135873
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMT201400
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME135873
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: