Provider Demographics
NPI:1174763643
Name:VITO, COURTNEY ANNE (MD)
Entity type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:ANNE
Last Name:VITO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:COURTNEY
Other - Middle Name:ANNE
Other - Last Name:SEVERINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2141 N HARBOR BLVD STE 33001
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3827
Mailing Address - Country:US
Mailing Address - Phone:714-446-5296
Mailing Address - Fax:714-665-4690
Practice Address - Street 1:2141 N HARBOR BLVD STE 33001
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3827
Practice Address - Country:US
Practice Address - Phone:714-446-5296
Practice Address - Fax:714-665-4690
Is Sole Proprietor?:No
Enumeration Date:2009-02-24
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV17320208600000X
CAA108301208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery