Provider Demographics
NPI:1760455463
Name:VITTI, GARY JOHN (MS,AT,C)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:JOHN
Last Name:VITTI
Suffix:
Gender:M
Credentials:MS,AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 13TH ST
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-4833
Mailing Address - Country:US
Mailing Address - Phone:310-426-6080
Mailing Address - Fax:310-426-6109
Practice Address - Street 1:636 13TH ST
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-4833
Practice Address - Country:US
Practice Address - Phone:310-426-6080
Practice Address - Fax:310-426-6109
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAKERS32Medicare UPIN