Provider Demographics
NPI:1396818753
Name:VASSALLO, FRANK A (DO)
Entity Type:Individual
Prefix:
First Name:FRANK
Middle Name:A
Last Name:VASSALLO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 ROUTE 73 N
Mailing Address - Street 2:SUITE I
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-1283
Mailing Address - Country:US
Mailing Address - Phone:856-983-7100
Mailing Address - Fax:
Practice Address - Street 1:801 ROUTE 73 N
Practice Address - Street 2:STE I
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-1283
Practice Address - Country:US
Practice Address - Phone:856-983-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB053990002084P0800X, 2084P0804X
PAOS-007105-E2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ054315Medicare PIN
F61501Medicare UPIN