Provider Demographics
NPI:1396801759
Name:VITALE, GERARD F (MD)
Entity type:Individual
Prefix:DR
First Name:GERARD
Middle Name:F
Last Name: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 1:1 SCHOOL STREET
Mailing Address - Street 2:SUITE 205
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542
Mailing Address - Country:US
Mailing Address - Phone:516-759-5559
Mailing Address - Fax:516-759-1671
Practice Address - Street 1:1 SCHOOL STREET
Practice Address - Street 2:SUITE 205
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542
Practice Address - Country:US
Practice Address - Phone:516-759-5559
Practice Address - Fax:516-759-1671
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY154983174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01088288Medicaid
NY27E411Medicare ID - Type Unspecified
NY01088288Medicaid