Provider Demographics
NPI:1477810067
Name:VITAL, JOHNATHAN (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHNATHAN
Middle Name:
Last Name:VITAL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 ALTENBURG CT
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603
Mailing Address - Country:US
Mailing Address - Phone:301-653-8828
Mailing Address - Fax:202-558-7113
Practice Address - Street 1:2413 ALTENBURG CT
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603
Practice Address - Country:US
Practice Address - Phone:301-653-8828
Practice Address - Fax:202-558-7113
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04759103G00000X, 103T00000X
DCPSY1000614103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist