Provider Demographics
NPI:1700835030
Name:VITELLI, THEODORE M (OD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:M
Last Name:VITELLI
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 1:65 SEA STREET EXT
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-5109
Mailing Address - Country:US
Mailing Address - Phone:508-775-0881
Mailing Address - Fax:
Practice Address - Street 1:65 SEA STREET EXT
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-5109
Practice Address - Country:US
Practice Address - Phone:508-775-0881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0EG000424152W00000X
MA4824152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110087501AMedicaid
MA001882101Medicare PIN
U72891Medicare UPIN
PA004645HMEMedicare PIN