Provider Demographics
NPI:1023302593
Name:VALTSIS, VLADISLAV (DO)
Entity type:Individual
Prefix:DR
First Name:VLADISLAV
Middle Name:
Last Name:VALTSIS
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 1:1000 BLYTHE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5812
Mailing Address - Country:US
Mailing Address - Phone:704-355-0720
Mailing Address - Fax:704-355-5948
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-0720
Practice Address - Fax:704-355-5948
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-00213207R00000X
PAOT014170207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1023302593Medicaid
SCNC2386Medicaid
NC1023302593Medicaid
NCNCQ176DMedicare UPIN
SCNC2386Medicaid
NCNCQ176CMedicare PIN