Provider Demographics
NPI:1154402030
Name:VITOULIS, M JOSEPH (DO)
Entity type:Individual
Prefix:
First Name:M
Middle Name:JOSEPH
Last Name:VITOULIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563
Mailing Address - Country:US
Mailing Address - Phone:516-593-0406
Mailing Address - Fax:516-593-0406
Practice Address - Street 1:120 BROADWAY
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563
Practice Address - Country:US
Practice Address - Phone:516-593-0406
Practice Address - Fax:516-593-0406
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205528204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01918905Medicaid
H26750Medicare UPIN
NY01918905Medicaid