Provider Demographics
NPI:1679884068
Name:VITALE, CHRISTOPHER ROBERT (DO)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:ROBERT
Last Name:VITALE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5052 N CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5822
Mailing Address - Country:US
Mailing Address - Phone:260-484-8551
Mailing Address - Fax:260-482-5060
Practice Address - Street 1:5050 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5886
Practice Address - Country:US
Practice Address - Phone:260-484-8551
Practice Address - Fax:260-482-5060
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018805207X00000X
CA20A14021207X00000X
IN02004802A207XX0801X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
12488756OtherCAQH
IN201368500Medicaid
IN201368500Medicaid