Provider Demographics
NPI:1720971328
Name:VITALLY DOC
Entity type:Organization
Organization Name:VITALLY DOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MAYELIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARPIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-842-6816
Mailing Address - Street 1:4755 SUMMERLIN RD STE 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-1073
Mailing Address - Country:US
Mailing Address - Phone:239-842-6816
Mailing Address - Fax:239-221-0478
Practice Address - Street 1:4755 SUMMERLIN RD STE 2
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-1073
Practice Address - Country:US
Practice Address - Phone:239-842-6816
Practice Address - Fax:239-221-0478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-02
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty