Healthcare Provider Details

I. General information

NPI: 1932135639
Provider Name (Legal Business Name): GINA GENOVEFFA VITIELLO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 05/05/2020
Certification Date: 05/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 CONCETTA SASS DR
RANDOLPH MA
02368-1812
US

IV. Provider business mailing address

680 CENTRE ST ATTN: PROVIDER ENROLLMENT
BROCKTON MA
02302-3308
US

V. Phone/Fax

Practice location:
  • Phone: 781-767-3276
  • Fax: 781-767-3276
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number159786
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: