Healthcare Provider Details

I. General information

NPI: 1174763643
Provider Name (Legal Business Name): COURTNEY ANNE VITO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COURTNEY ANNE SEVERINO MD

II. Dates (important events)

Enumeration Date: 02/24/2009
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2141 N HARBOR BLVD STE 33001
FULLERTON CA
92835-3827
US

IV. Provider business mailing address

2141 N HARBOR BLVD STE 33001
FULLERTON CA
92835-3827
US

V. Phone/Fax

Practice location:
  • Phone: 714-446-5296
  • Fax: 714-665-4690
Mailing address:
  • Phone: 714-446-5296
  • Fax: 714-665-4690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number17320
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA108301
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: