Provider Demographics
NPI:1811232770
Name:VITASTAT MEDICAL PLLC
Entity Type:Organization
Organization Name:VITASTAT MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-300-8296
Mailing Address - Street 1:8738 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-4802
Mailing Address - Country:US
Mailing Address - Phone:917-300-8296
Mailing Address - Fax:917-300-8296
Practice Address - Street 1:2322 BROADWAY
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-4196
Practice Address - Country:US
Practice Address - Phone:917-300-8296
Practice Address - Fax:917-300-8296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY254736261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty