Provider Demographics
NPI:1932135639
Name:VITIELLO, GINA GENOVEFFA (MD)
Entity Type:Individual
Prefix:DR
First Name:GINA
Middle Name:GENOVEFFA
Last Name:VITIELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 CENTRE ST
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:47 CONCETTA SASS DR
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-1812
Practice Address - Country:US
Practice Address - Phone:781-767-3276
Practice Address - Fax:781-767-3276
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
MA1597862084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS4000151804Medicare PIN