Provider Demographics
NPI:1629048194
Name:VITO, KENNETH J (MD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:J
Last Name:VITO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:7580 AUBURN ROAD
Mailing Address - Street 2:#103
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077
Mailing Address - Country:US
Mailing Address - Phone:440-352-1474
Mailing Address - Fax:440-352-2662
Practice Address - Street 1:7580 AUBURN ROAD
Practice Address - Street 2:#103
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077
Practice Address - Country:US
Practice Address - Phone:440-352-1474
Practice Address - Fax:440-352-2662
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-069985174400000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0244533Medicaid
OH000000133450OtherANTHEM
OH54721OtherQUALCHOICE
OH104635OtherKAISER
OH3415313198A14OtherBCBS
OH040013864OtherTRAVELERS RAILROAD MEDICA
OH0244533Medicaid
OH0807154Medicare PIN