Provider Demographics
NPI:1609962570
Name:VITALE, JAMES A (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:A
Last Name:VITALE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1600 W LAKE ST
Mailing Address - Street 2:UNIT 106
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-1822
Mailing Address - Country:US
Mailing Address - Phone:630-773-9410
Mailing Address - Fax:630-773-9473
Practice Address - Street 1:1600 W LAKE ST
Practice Address - Street 2:UNIT 106
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-1822
Practice Address - Country:US
Practice Address - Phone:630-773-9410
Practice Address - Fax:630-773-9473
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL046007948152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364078970OtherTAX ID
IL02232964OtherBLUE CROSS BLUE SHIELD
IL02232964OtherBLUE CROSS BLUE SHIELD
IL5827650001Medicare NSC
IL364078970OtherTAX ID