Basic Information
Provider Information | |||||||||
NPI: | 1174763643 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VITO | ||||||||
FirstName: | COURTNEY | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SEVERINO | ||||||||
OtherFirstName: | COURTNEY | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2141 N HARBOR BLVD STE 33001 | ||||||||
Address2: |   | ||||||||
City: | FULLERTON | ||||||||
State: | CA | ||||||||
PostalCode: | 928353827 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7144465296 | ||||||||
FaxNumber: | 7146654690 | ||||||||
Practice Location | |||||||||
Address1: | 2141 N HARBOR BLVD STE 33001 | ||||||||
Address2: |   | ||||||||
City: | FULLERTON | ||||||||
State: | CA | ||||||||
PostalCode: | 928353827 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7144465296 | ||||||||
FaxNumber: | 7146654690 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/24/2009 | ||||||||
LastUpdateDate: | 04/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 17320 | NV | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | A108301 | CA | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.