Provider Demographics
NPI:1215986823
Name:VERTKIN, GENNADY (MD)
Entity type:Individual
Prefix:
First Name:GENNADY
Middle Name:
Last Name:VERTKIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GENE
Other - Middle Name:
Other - Last Name:VERTKIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:301 NW 82ND AVE
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-1811
Mailing Address - Country:US
Mailing Address - Phone:954-693-8600
Mailing Address - Fax:954-452-2693
Practice Address - Street 1:750 12TH AVE
Practice Address - Street 2:BAYLOR SURGICAL HOSPITAL FORT WORTH
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-334-5050
Practice Address - Fax:817-334-0235
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2854207L00000X
FLME48681207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D20859Medicare UPIN
TX8G2040Medicare PIN