Provider Demographics
NPI:1083601256
Name:VITHALA, ANIL K (MD)
Entity Type:Individual
Prefix:DR
First Name:ANIL
Middle Name:K
Last Name:VITHALA
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 1:477 CONNECTICUT BLVD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3268
Mailing Address - Country:US
Mailing Address - Phone:860-289-0623
Mailing Address - Fax:
Practice Address - Street 1:477 CONNECTICUT BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3268
Practice Address - Country:US
Practice Address - Phone:860-289-0623
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034801207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010034801CT01OtherANTHEM
01034801OtherCIGNA
G09338Medicare UPIN