Provider Demographics
NPI:1730189556
Name:VITALE, GLENN CHARLES (DPM)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:CHARLES
Last Name:VITALE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
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Mailing Address - Street 1:90A BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-8060
Mailing Address - Country:US
Mailing Address - Phone:203-877-3160
Mailing Address - Fax:
Practice Address - Street 1:385 MAIN ST
Practice Address - Street 2:SUITE 10
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-4312
Practice Address - Country:US
Practice Address - Phone:203-933-8606
Practice Address - Fax:203-932-9571
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTP00345213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004060828Medicaid
CT480000377Medicare PIN
CT004060828Medicaid