MEDICARE: IMELDA L VITAL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	247815-1	NY

General Provider Information

NPI Number	:	1821405887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IMELDA L VITAL M.D.

Provider Business Mailing Address
First Line	:	3223 CHURCH AVE
Second Line	:	NEW YORK AVENUE MEDICAL
City	:	BROOKLYN
State	:	NY
Zip	:	11226-4213
Country	:	US
Telephone Number	:	718-693-4900
Fax Number	:	718-287-8946

Provider Business Practice Location Address
First Line	:	3223 CHURCH AVE
Second Line	:	NEW YORK AVENUE MEDICAL
City	:	BROOKLYN
State	:	NY
Zip	:	11226-4213
Country	:	US
Telephone Number	:	718-693-4900
Fax Number	:	718-287-8946

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2014
Last Update Date	:	07/22/2014

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