Provider Demographics
NPI:1225090004
Name:VITO, LIESE K (MD)
Entity Type:Individual
Prefix:
First Name:LIESE
Middle Name:K
Last Name:VITO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LIESE
Other - Middle Name:
Other - Last Name:KASPAREK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 781389
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1389
Mailing Address - Country:US
Mailing Address - Phone:440-918-4630
Mailing Address - Fax:440-918-4632
Practice Address - Street 1:4176 STATE ROUTE 306
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-9203
Practice Address - Country:US
Practice Address - Phone:440-918-4630
Practice Address - Fax:440-918-4654
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-065098207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0152525Medicaid
OHG07838Medicare UPIN
OH0786933Medicare PIN