Healthcare Provider Details

I. General information

NPI: 1932085305
Provider Name (Legal Business Name): GAMMA NEURO DIAGNOSTICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2025
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 SUPERIOR AVE STE 200A
NEWPORT BEACH CA
92663-3664
US

IV. Provider business mailing address

PO BOX 2277
VENICE CA
90294-2277
US

V. Phone/Fax

Practice location:
  • Phone: 949-764-8430
  • Fax: 310-691-1394
Mailing address:
  • Phone:
  • 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:
Phone: 310-923-1437