Provider Demographics
NPI:1013070176
Name:VITAL, JOELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOELLE
Middle Name:
Last Name:VITAL
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 1:953 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11553-1543
Mailing Address - Country:US
Mailing Address - Phone:516-414-1101
Mailing Address - Fax:516-414-1131
Practice Address - Street 1:953 FRONT ST
Practice Address - Street 2:
Practice Address - City:UNIONDALE
Practice Address - State:NY
Practice Address - Zip Code:11553-1543
Practice Address - Country:US
Practice Address - Phone:516-414-1101
Practice Address - Fax:516-414-1131
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234089207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03278948Medicaid
NY2687236Medicaid