Healthcare Provider Details

I. General information

NPI: 1730189556
Provider Name (Legal Business Name): GLENN CHARLES VITALE D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 11/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 MAIN ST SUITE 10
WEST HAVEN CT
06516-4312
US

IV. Provider business mailing address

90A BEACH AVE
MILFORD CT
06460-8060
US

V. Phone/Fax

Practice location:
  • Phone: 203-933-8606
  • Fax: 203-932-9571
Mailing address:
  • Phone: 203-877-3160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberP00345
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: