1306012745 NPI number — PETER A VITULLI JR D O P A

Table of content: (NPI 1306012745)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306012745 NPI number — PETER A VITULLI JR D O P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETER A VITULLI JR D O P A
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
A CENTER FOR DERMATOLOGY COSMETIC AND LASER SURGERY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306012745
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4600 MILITARY TRL
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
JUPITER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33458-4810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-427-2000
Provider Business Mailing Address Fax Number:
561-776-2565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4600 MILITARY TRL
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
JUPITER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33458-4810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-427-2000
Provider Business Practice Location Address Fax Number:
561-776-2565
Provider Enumeration Date:
05/06/2008

Additional Information

Authorized Official

Authorized Official Last Name:
VITULLI
Authorized Official First Name:
PETER
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PHYSICIAN/CEO
Authorized Official Telephone Number:
561-427-2000

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  OS8005 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 81700 . This is a "MEDICARE- ID TYPE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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