Provider Demographics
NPI:1386654408
Name:VASSALLO, BRETT JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:JOSEPH
Last Name:VASSALLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1875 DEMPSTER ST STE 665
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1168
Mailing Address - Country:US
Mailing Address - Phone:847-825-1590
Mailing Address - Fax:847-825-1604
Practice Address - Street 1:1875 DEMPSTER ST
Practice Address - Street 2:#665
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068
Practice Address - Country:US
Practice Address - Phone:847-825-1590
Practice Address - Fax:847-825-1604
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097455207VG0400X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036097455Medicaid