Provider Demographics
NPI:1720299035
Name:VITALE, GEORGE
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:VITALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6051 PACIFIC BLVD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-2933
Mailing Address - Country:US
Mailing Address - Phone:323-583-9999
Mailing Address - Fax:323-583-1344
Practice Address - Street 1:6051 PACIFIC BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-2933
Practice Address - Country:US
Practice Address - Phone:323-583-9999
Practice Address - Fax:323-583-1344
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician