Healthcare Provider Details

I. General information

NPI: 1932142114
Provider Name (Legal Business Name): PAUL L VITULLI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 12/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 A1A N SUITE 322
PONTE VEDRA BEACH FL
32082-1823
US

IV. Provider business mailing address

915 W MONROE ST STE 100
JACKSONVILLE FL
32204-1177
US

V. Phone/Fax

Practice location:
  • Phone: 904-551-0703
  • Fax: 904-551-0709
Mailing address:
  • Phone: 904-518-1398
  • Fax: 904-513-0231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOS10498
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberOS10498
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: