Provider Demographics
NPI:1902866577
Name:LA FATA, VITO (MD)
Entity Type:Individual
Prefix:
First Name:VITO
Middle Name:
Last Name:LA FATA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 E REPUBLIC RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-6530
Mailing Address - Country:US
Mailing Address - Phone:417-889-6102
Mailing Address - Fax:417-889-6289
Practice Address - Street 1:3801 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5210
Practice Address - Country:US
Practice Address - Phone:417-269-4056
Practice Address - Fax:417-269-5556
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050203452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1256OtherBLUE
MOP00261688OtherRRR MEDICARE
AR160773001Medicaid
MO207239005Medicaid
MO933930242Medicare PIN
MO1256OtherBLUE