Provider Demographics
NPI:1720099856
Name:VITALE, CHARLENE (MD)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:VITALE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHARLENE
Other - Middle Name:V
Other - Last Name:CONNERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2561 LAC DE VILLE BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-5645
Mailing Address - Country:US
Mailing Address - Phone:585-424-3410
Mailing Address - Fax:585-214-0042
Practice Address - Street 1:2561 LAC DE VILLE BLVD
Practice Address - Street 2:STE 100
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-5645
Practice Address - Country:US
Practice Address - Phone:585-424-3410
Practice Address - Fax:585-214-0042
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2017-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186511207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF33732Medicare UPIN