Provider Demographics
NPI:1396360319
Name:DR MICHAEL VASSALLO, INC
Entity Type:Organization
Organization Name:DR MICHAEL VASSALLO, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:VASSALLO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:201-913-6088
Mailing Address - Street 1:335 WYCKOFF AVE
Mailing Address - Street 2:
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-2237
Mailing Address - Country:US
Mailing Address - Phone:201-913-6088
Mailing Address - Fax:
Practice Address - Street 1:335 WYCKOFF AVE
Practice Address - Street 2:
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481-2237
Practice Address - Country:US
Practice Address - Phone:201-913-6088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25-MB059472-00OtherMEDICAL LICENSE