Provider Demographics
NPI:1922193127
Name:VITALE, THOMAS DAVID (DPM)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:DAVID
Last Name:VITALE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:HASBROUCK HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07604-1208
Mailing Address - Country:US
Mailing Address - Phone:201-288-2242
Mailing Address - Fax:201-288-7372
Practice Address - Street 1:160 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:HASBROUCK HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:07604-1208
Practice Address - Country:US
Practice Address - Phone:201-288-2242
Practice Address - Fax:201-288-7372
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003991213ES0131X
MI5901400130213ES0103X
NJ25MD00175100213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJVI453487Medicare ID - Type Unspecified
NJT45335Medicare UPIN