Provider Demographics
NPI:1841395662
Name:VITELLI, PHILIP G (DO)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:G
Last Name:VITELLI
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 1:15801 W HURON DR
Mailing Address - Street 2:
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-6699
Mailing Address - Country:US
Mailing Address - Phone:623-570-0511
Mailing Address - Fax:623-223-5665
Practice Address - Street 1:15801 W HURON DR
Practice Address - Street 2:
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-6699
Practice Address - Country:US
Practice Address - Phone:623-570-0511
Practice Address - Fax:623-223-5665
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS002620L2084P0800X
AZ51172084P0800X
NVDO16552084P0800X
MI51010196132084P0800X
CA20A132332084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ394428Medicaid
AZ394428Medicaid
AZZ145801Medicare PIN
PA067571P0TMedicare PIN
AZZ145801Medicare PIN