Healthcare Provider Details

I. General information

NPI: 1083024145
Provider Name (Legal Business Name): DANIEL VITANTONIO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 12/11/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20331 IRVINE AVE STE E2
NEWPORT BEACH CA
92660-0223
US

IV. Provider business mailing address

PO BOX 2277
VENICE CA
90294-2277
US

V. Phone/Fax

Practice location:
  • Phone: 949-228-9676
  • Fax: 877-987-7729
Mailing address:
  • Phone: 310-923-1437
  • Fax: 310-439-3701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number20835
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberT1593
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA143344
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301502449
License Number StateMI
# 5
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberA143344
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: