Provider Demographics
NPI:1780805069
Name:VITAL, LOUIS GESSAI (MD)
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:GESSAI
Last Name:VITAL
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 1:3223 CHURCH AVENUE
Mailing Address - Street 2:DIPLOMATE AMERICAN BOARD OF INTERNAL MEDICINE
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-4213
Mailing Address - Country:US
Mailing Address - Phone:718-693-4900
Mailing Address - Fax:718-287-8946
Practice Address - Street 1:3223 CHURCH AVENUE
Practice Address - Street 2:DIPLOMATE AMERICAN BOARD OF INTERNAL MEDICINE
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-4213
Practice Address - Country:US
Practice Address - Phone:718-693-4900
Practice Address - Fax:718-287-8946
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2014-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155005207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
172308OtherWELLCARE
NY00812208Medicaid
0097153OtherGHI
NY00812208Medicaid
172308OtherWELLCARE