Provider Demographics
NPI:1336128867
Name:VITALE, GARY C (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:C
Last Name:VITALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:401 E CHESTNUT ST
Mailing Address - Street 2:STE 710
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-5700
Mailing Address - Country:US
Mailing Address - Phone:502-583-8303
Mailing Address - Fax:502-584-0302
Practice Address - Street 1:401 E CHESTNUT ST
Practice Address - Street 2:STE 710
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-5700
Practice Address - Country:US
Practice Address - Phone:502-583-8303
Practice Address - Fax:502-584-0302
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY20934208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100344390AMedicaid
KY1051082OtherPASSPORT
KY64209349Medicaid
IN100344390AMedicaid
KY64209349Medicaid