Healthcare Provider Details

I. General information

NPI: 1093834954
Provider Name (Legal Business Name): VICTORIA VITALE-LEWIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 03/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 4TH AVE
MELBOURNE FL
32951-2545
US

IV. Provider business mailing address

504 4TH AVE
MELBOURNE FL
32951-2545
US

V. Phone/Fax

Practice location:
  • Phone: 321-698-8210
  • Fax: 321-698-8210
Mailing address:
  • Phone: 321-698-8210
  • Fax: 321-723-7397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberME0050929
License Number StateFL

VIII. Authorized Official

Name: VICTORIA VITALE- VITALE-LEWIS
Title or Position: OWNER,PRESIDENT
Credential: M.D., P.A.
Phone: 321-698-8210