Healthcare Provider Details

I. General information

NPI: 1326156787
Provider Name (Legal Business Name): NEIL B VITALE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E PECAN ST
ALTUS OK
73521-6141
US

IV. Provider business mailing address

1200 E PECAN ST
ALTUS OK
73521-6141
US

V. Phone/Fax

Practice location:
  • Phone: 580-379-5547
  • Fax:
Mailing address:
  • Phone: 580-379-5547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number029104
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number30161
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: