Provider Demographics
NPI:1275590119
Name:VASSALLO, JOHN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:VASSALLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1225 W GRAND RIVER AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-3970
Mailing Address - Country:US
Mailing Address - Phone:517-548-0010
Mailing Address - Fax:517-548-5326
Practice Address - Street 1:1225 W GRAND RIVER AVE STE 300
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-3970
Practice Address - Country:US
Practice Address - Phone:517-548-0010
Practice Address - Fax:517-548-5326
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJV078585207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJV078585OtherBLUE CROSS LICENSE #
MI104848196Medicaid
MI104848196Medicaid