Basic Information
Provider Information | |||||||||
NPI: | 1730176868 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VITALE | ||||||||
FirstName: | KENNETH | ||||||||
MiddleName: | CRAIG | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 350 DICKINSON ST | ||||||||
Address2: | SUITE 121 | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921031913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6195432539 | ||||||||
FaxNumber: | 6195432540 | ||||||||
Practice Location | |||||||||
Address1: | 350 DICKINSON ST | ||||||||
Address2: | SUITE 121 | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921031913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6195432539 | ||||||||
FaxNumber: | 6195432540 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2005 | ||||||||
LastUpdateDate: | 01/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | C132964 | CA | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 2081S0010X | C132964 | CA | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine |
No ID Information.