Provider Demographics
NPI:1073699864
Name:VITA, GARY MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:MICHAEL
Last Name:VITA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 BOSLEY AVE
Mailing Address - Street 2:SUITE C6
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-4328
Mailing Address - Country:US
Mailing Address - Phone:410-337-5337
Mailing Address - Fax:410-337-5338
Practice Address - Street 1:7505 OSLER DR
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7736
Practice Address - Country:US
Practice Address - Phone:410-337-5337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0046107207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
4E67000004OtherFEDERAL BCBS
53351803OtherBCBS
MD050063100OtherRAILROAD MEDICARE
MD160131800Medicaid
53351803OtherBCBS
F97567Medicare UPIN