Provider Demographics
NPI:1992156582
Name:VENDITTELLI, CARLISLE A (MD)
Entity type:Individual
Prefix:
First Name:CARLISLE
Middle Name:A
Last Name:VENDITTELLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARLISLE
Other - Middle Name:A
Other - Last Name:HEINSELMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:43900 GARFIELD RD STE 222
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:43900 GARFIELD RD STE 222
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038
Practice Address - Country:US
Practice Address - Phone:586-286-0050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301117066207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine