Provider Demographics
NPI:1093834954
Name:VICTORIA VITALE-LEWIS
Entity Type:Organization
Organization Name:VICTORIA VITALE-LEWIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:VITALE-
Authorized Official - Last Name:VITALE-LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:321-698-8210
Mailing Address - Street 1:504 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32951-2545
Mailing Address - Country:US
Mailing Address - Phone:321-698-8210
Mailing Address - Fax:321-723-7397
Practice Address - Street 1:504 4TH AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32951-2545
Practice Address - Country:US
Practice Address - Phone:321-698-8210
Practice Address - Fax:321-698-8210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00509292086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD84765Medicare UPIN