Provider Demographics
NPI:1932142114
Name:VITULLI, PAUL L (DO)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:L
Last Name:VITULLI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:915 W MONROE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-1177
Mailing Address - Country:US
Mailing Address - Phone:904-518-1398
Mailing Address - Fax:904-513-0231
Practice Address - Street 1:330 A1A N
Practice Address - Street 2:SUITE 322
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-1823
Practice Address - Country:US
Practice Address - Phone:904-551-0703
Practice Address - Fax:904-551-0709
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS104982085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000818800Medicaid
FLBM568YMedicare PIN