Provider Demographics
NPI:1730176868
Name:VITALE, KENNETH CRAIG (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:CRAIG
Last Name:VITALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 DICKINSON ST
Mailing Address - Street 2:SUITE 121
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1913
Mailing Address - Country:US
Mailing Address - Phone:619-543-2539
Mailing Address - Fax:619-543-2540
Practice Address - Street 1:350 DICKINSON ST
Practice Address - Street 2:SUITE 121
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-1913
Practice Address - Country:US
Practice Address - Phone:619-543-2539
Practice Address - Fax:619-543-2540
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2015-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC132964208100000X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1207J1Medicare ID - Type Unspecified
NYI33377Medicare UPIN