Provider Demographics
NPI:1336165026
Name:VITELLO, PETER JOHN (MSPT)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:JOHN
Last Name:VITELLO
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10550 INDEPENDENCE POINTE PKWY
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-2690
Mailing Address - Country:US
Mailing Address - Phone:704-849-9393
Mailing Address - Fax:
Practice Address - Street 1:10550 INDEPENDENCE POINTE PKWY
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-2690
Practice Address - Country:US
Practice Address - Phone:704-849-9393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10450225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC250111Medicare PIN