Provider Demographics
NPI:1942348263
Name:GONZALEZ-VITALE, JUAN CARLOS (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:CARLOS
Last Name:GONZALEZ-VITALE
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 1:2801 N GANTENBEIN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1623
Mailing Address - Country:US
Mailing Address - Phone:503-413-4813
Mailing Address - Fax:503-413-2982
Practice Address - Street 1:2801 N GANTENBEIN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1623
Practice Address - Country:US
Practice Address - Phone:503-413-4813
Practice Address - Fax:503-413-2982
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16262207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR036629Medicaid
OR0134819Medicaid
036629OtherOREGON WELFARE
220024469Medicare PIN
036629OtherOREGON WELFARE
F07150Medicare UPIN
G8879724Medicare PIN
R00WCMBLCMedicare PIN
R00WCZBQBMedicare PIN