Healthcare Provider Details

I. General information

NPI: 1164664421
Provider Name (Legal Business Name): VITALY IZGUR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 BITTERSWEET DR
DOYLESTOWN PA
18901-2770
US

IV. Provider business mailing address

4040 E CAMELBACK RD STE 250
PHOENIX AZ
85018-8350
US

V. Phone/Fax

Practice location:
  • Phone: 208-416-2932
  • Fax:
Mailing address:
  • Phone: 855-687-7237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberMD442174
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101271954
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number0101271954
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD442174
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier110313200
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: