Provider Demographics
NPI:1124373600
Name:VASSALLO, STEFANO MICHAEL (MSED)
Entity Type:Individual
Prefix:MR
First Name:STEFANO
Middle Name:MICHAEL
Last Name:VASSALLO
Suffix:
Gender:M
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 LYRIC PL
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-7819
Mailing Address - Country:US
Mailing Address - Phone:631-425-2684
Mailing Address - Fax:
Practice Address - Street 1:5 LYRIC PL
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-7819
Practice Address - Country:US
Practice Address - Phone:631-425-2684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist