Provider Demographics
NPI:1164458972
Name:VITKUS, JOHN S (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:VITKUS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:324 E 10TH AVE STE 178
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-2885
Practice Address - Country:US
Practice Address - Phone:801-408-8500
Practice Address - Fax:801-408-8510
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11351485-2501103T00000X
OH5437103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2141435Medicaid
OH2141435Medicaid