Provider Demographics
NPI:1093729204
Name:VASSALLO, MICHAEL
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:VASSALLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 STIRLING RD
Mailing Address - Street 2:
Mailing Address - City:WATCHUNG
Mailing Address - State:NJ
Mailing Address - Zip Code:07069-5900
Mailing Address - Country:US
Mailing Address - Phone:908-769-0912
Mailing Address - Fax:
Practice Address - Street 1:40 STIRLING RD
Practice Address - Street 2:
Practice Address - City:WATCHUNG
Practice Address - State:NJ
Practice Address - Zip Code:07069-5900
Practice Address - Country:US
Practice Address - Phone:908-769-0912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05947200207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ783338Medicare ID - Type Unspecified