Healthcare Provider Details

I. General information

NPI: 1003683848
Provider Name (Legal Business Name): GAMMA NEURO NETWORK OF TEXAS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 WASHINGTON BLVD
MARINA DEL REY CA
90292-5287
US

IV. Provider business mailing address

PO BOX 2277
VENICE CA
90294-2277
US

V. Phone/Fax

Practice location:
  • Phone: 310-923-1437
  • Fax:
Mailing address:
  • Phone: 310-923-1437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL VITANTONIO
Title or Position: PRESIDENT
Credential: MD
Phone: 310-923-1437