Provider Demographics
NPI:1225289952
Name:PITALE, SEAN N (OD)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:N
Last Name:PITALE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 CAMPUS RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-5077
Mailing Address - Country:US
Mailing Address - Phone:704-234-1930
Mailing Address - Fax:704-234-1940
Practice Address - Street 1:4101 CAMPUS RIDGE RD
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5077
Practice Address - Country:US
Practice Address - Phone:704-234-1930
Practice Address - Fax:704-234-1940
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1529152W00000X
PAOEG002130152W00000X
NC2166152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5920824Medicaid
SCD15295Medicaid
0381OtherMEDICARE GROUP NUMBER FOR EMPLOYEE DR
SC3063OtherMEDICARE GROUP NUMBER
NC5920824Medicaid
SC3063OtherMEDICARE GROUP NUMBER
AA35420381Medicare PIN